A Practical Approach To Improving patient flow using The Theory of Constraints

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A Practical Approach To Improving patient flow
using The Theory of Constraints

• Oxford Radcliffe NHS Trust

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Oxford Radcliffe Hospitals Trust

• The Trust has nearly 1,500 beds
• 400,000 people attended outpatients
• 112,000 patients were admitted
• 90,000 accident and emergency attendees
• 7,000 babies were delivered.
• Over 10,000 staff work in the organisation

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What is The Theory of Constraints?

• Eliyahu Goldratt first used in industry -
• Thinking Tool
• Not a set of solutions
• Focus for Change
• Whole systems approach
• Simple common sense steps

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TOC Process 5 Steps

• (Step 0 - Map the System)
• Step 1 - Identify the Constraint
• Step 2 - Get the most out of the constraint
• Step 3 - Support the systems constraint
• Step 4 - Elevate the systems constraint
• Step 5 - Go back to step 1

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Rate Limiting Step Weakest Link
Referral
OPD
Waiting list
Pre assessment
surgery
OPD
100
60
60
50
25
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Types Of Constraint

• Find The rate limiting factor
• Physical bottleneck a capacity limited resource
• Thinking Constraint Weve always done it like
  that
• Policy Constraint an organisational policy
  whether written or believed

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Constraint V Bottleneck

• Bottleneck Any resource whose capacity is less
  than the demand placed upon it.
• Constraint Bottlenecks come and go. A constraint
  limits the whole systems performance over an
  extended period of time.

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Benefits of Mapping

• Gain Agreement on what is Whole System
• Identify True Constraint
• Highlight queues time span
• Identify other bottlenecks/issues
• Starting point for redesign
• Step 5 Cause effect

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TOC as a Generic Tool

• Principles may be applied to any whole System
• Gynaecology
• PND Ultrasound
• MaxilloFacial/ Orthodontics
• Urology
• Finance
• Horton General Hospital

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Case Study Horton General

• District general hospital 240beds
• 2000 2001 Long Trolley Waits
• High Cancellation of electives due tono beds
  available.

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Introduction Of TOC

• April 2001 Capacity group formed
• April 2001 TOC Workshop for key stakeholders
• May 2001 System mapping and analysis

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HGH Identify the Constraint
Medicine
Discharge
AE
Treatment
Surgery
PCT
Social Care
Waiting List
Discharge
Trauma Ortho
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5 Steps of TOC

• Step 1 Identify the constraint Nursed beds
• Step 2 Get the most out of the constraint
• 24hour stays, bed usage by AE.
• Location of Day case patients
  

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Step 2 Get the most out of the constraint!

• Not about working harder.
• Constraint should only work on core role
  otherwise capacity wasted.
• Nursed beds most appropriate use of bed stock
  nursing activity
• Starting point for analysis

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Maximise Efficiency
24 hour or less time as IP
Referrals into AE
AE
PCT
Information
Nursed beds
Waiting List
Inpatient or Day case
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Information

• 25 of admissions through AE stayed 24 hours or
  less of those
• - 25 non specific chest pain
• - 18 self harm
• Minimal day case activity found in inpatient
  areas.
• PCT AE used appropriately by GPs

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Information V Anecdote

• Many decisions about waiting times are based on
  anecdote not fact!

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5 Steps

• Step 3 Support the constraint New ways to offload
  the constraint.
• Emergency transfer beds existing area
• Discharge Lounge Old children's ward
• Discharge ward

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5 Steps of TOC

• Step 4 Elevate the constraint
• Discharge Beds - increase in capacity
• New build for Emergency transfer Beds
• Step 5 Go Back

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Results so far.

• Trolley waits reduced
• Over 80 of patients are admitted within 4 hours
  of decision to admit in AE
• Number of elective cancellations reduced.

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Results
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Emergency Admissions Surgical Cancellations ( no beds)
December 2000 582 18
December 2001 654 13
January 2001 599 50
January 2002 654 21
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Discharge beds
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Lessons Learnt

• More efficient to pull patients through the
  system than push
• Process mapping essential to understand the
  system
• Accurate, focused information is needed to
  diagnose problems and to measure success.

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Summary

• Theory of Constraints Common Sense approach to
  whole systems efficiency
• Promotes ownership of the problem by the staff
  delivering the service.
• Needs high level Sponsorship if it is to be
  effective.