Allied Healthcare Professions Service Improvement Projects Regional Event Process and Service Redesign Resource Pack.

Allied Healthcare Professions Service Improvement Projects

Regional Event

Process and Service Redesign Resource Pack

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Company Confidential

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

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W Shewhart – Statistical Process Control, PDSA

W E Deming – System of Profound Knowledge

20’s

50’s

(Toyota) Lean thinking

(Motorola) 6 Sigma

E Goldratt - Theory of Constraints

M Hammer - Business Process Re-engineering

Total Quality Management

90’s

30-40

70’s

80’s

Since the

1980s: Adapt,

not adopt in the NHS

Evolution of improvement

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Any improvement is a change– not every change is an improvement– but we cannot improve something unless

we change it

Eliyahu GoldrattGoldratt E (1990) Theory of Constraints, North River Press,

Massachusetts

Theory of constraints

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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

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NO2704-202

Process redesign

Eliminate waste

Linked processe

s

Match capacity

and demand

Reduce batching

Processmapping

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A process map

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NO2704-202

Process mapping

Every system is perfectly designed to get the results it achieves

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NO2704-202

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?

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NO2704-202

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

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Symptoms and examples of ‘waste’

Waste Symptom Example

Mistakes clinical incident complaints multiple checking systems

patient with more than one PAS number post-operative wound infection drug error equipment failure patient outlying on ‘wrong’ ward

Uncoordinated activity tests undertaken before they are needed and when they are not unnecessary

bed requested ‘just in case’

Stock poor ability to respond to problems

increased need for storage space

high level of work in progress

high volume of stock in departments high level of patients in the process, sitting

around waiting

Transportation movement of documents, materials and patients

ambulance conveys patient with minor injury to A&E department

patient outlying in wrong ward specimens transported to centralised

laboratory for processing

Unnecessary motion excessive walking poor layout of working environment

Inappropriate processing

high variation batching duplication

patients seen by many healthcare professionals when one would do

multiple data entry on information systems that do not communicate

patient details recorded on A&E ‘white boards’

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Calculating value added

5 3 5

20 120 35

Total Time = 188

TIME:

Value added time = 13

Total Steps = 20

Steps:

Value addingsteps = 3

s1

s3

s1

s4

s2

s9

Patient has

cardiac catheter

1

Secretary types letter

7

Letter dictated

to surgeon

2

Tape to ward

clerk

3Tape

sent topost room CHH

4

Tape sent to

post room HR

5

Tape sent to

secretary at HR

6

Secretary request angiogra

m

14a

Patient seen in clinic

19

Letter to surgeon

14

Letter to secretary for OPD

15

Letter to post room CHH

16

Letter to appoint-ments

17

Letter sent to

patient

18

Radio-grapher

finds angiogra

m

15a

Patient put on waiting

list

20

Angiogram given to porter

16a Angiogra

m delivered

to secretary

17a Angiogra

m reviewed

by surgeon

18a

Arteries suitable

for surgery

19a

Surgeon considers patient suitable

20a

Letter delivered

to secretary

13Letter to doctor

for signatur

e

8Letter sent to

post room CHH

12

Letter sent to

post room HR

11

Letter returned

to secretary

10

Letter signed

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Process map for cardiac referral

Simplified process

Patient has angiogram

1

Patient seen in clinic

6

Letter and angiogram

delivered to secretary

4

Data input into computer

2

Secretary make OPD

appointment

5

Angiogram tape

7

Print out data as

referral letter

3

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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

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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?

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0 20 40 60 80 100 120 140 160 180

Patient 3

Patient 2

Patient 1

minutes waited

Clinical Assessment

Investigations

Results

Clinical decision

Admission

Batching results

2hrs 50

2hrs 25

2hrs 15

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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

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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?

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time

Demand

Queue

Can’t pass unused capacity forward to next week

Capacity

Average demand = average capacity causes a queue

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• 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

Bottlenecks and constraints

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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)

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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

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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

Clinical decision

Treat-ment

Dis-charge

Admi-ssion

If 5 patients arrive an hour, how many patients need to move between each step each hour? If 10?

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Overall coordination

Clinical assessment

Investi-gations

Clinical decision

Admi-ssion

Treat-ment

Dis-charge

Flow manager

• 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

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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

Lindsay Winterton

Mobile 07801 376 011

e-mail: [email protected]

Allied Healthcare Professions Service Improvement Projects Regional Event Process and Service Redesign Resource Pack.

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