Managing Variation, Understanding the Effects of Carve-out, Scheduling and Flow

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Managing Variation, Understanding the Effects of
Carve-out, Scheduling and Flow
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How do we manage variation in demand?

• Delay
• Forced booking
• Carved out capacity

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Carve-out can be
Huge
Thousands of combinations It is impossible
to balance the queues
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The size of the carve out
Flexi-sig
Colonoscopy
OGD
ERCP
Number of appointment types
73 queues
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Queue type A
Queue type B
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Is all carve-out bad?

• Capacity for urgent cases (prioritisation of
  patients)
• Subspecialisation
• The issue is not to eliminate all carve-out, but
  rather to eliminate unnecessary carve-out and
  reduce the impact of carve-out we cant eliminate

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Terms

• Carve-out
• When the flow of one group of patients is
  improved at one bottleneck at the expense of
  another group of patients
• Streaming or segmentation
• Separation of the process of care along the whole
  pathway for one group of patients to improve
  overall flow but not at the expense of other
  groups of patients

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Analogy of segmentation and flow traffic flow
on motorway
Slow lane 50 mph Middle lane 70 mph Fast
lane 90 mph
All vehicles keep to same speed in allocated
lane and all progress according to their need
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What happens when lorry moves into middle lane at
55 mph?
Slow lane 50 mph Middle lane 70 mph Fast
lane 90 mph

• backlog of traffic
• actual consequences are not seen at point of
  bottleneck

• flow rates compromised

• few needs met

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Carve-out

• Carve-out interrupts the flow of patients and
  keeps them waiting (traffic lights)
• Concrete barriers so traffic cant move into
  spare space
• Cant match demand and capacity
• Queues galore

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When is it carve-out?

• When ring-fencing resources for one group reduces
  resource available for another group
• How can we tell whether the problem is carve-out
  or capacity?

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Demand exceeds capacity
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Carve out and churn
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Variation and carve-out

• Variation helps cause the waiting list
• Carve out makes it worse
• So what are we to do?

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Match capacity and demand!

• Set the maximum waiting time to the time the most
  urgent referral can afford to wait
• Do todays work today
• Do this weeks work this week
• Do this months work this month

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What do we want to achieve?

• Maximise Throughput
• Treat the maximum number of patients with the
  minimum amount of waiting
• How?

Wrong
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Flow

• We need to optimise the whole process - not each
  individual step
• Dont maximise utilisation, maximise throughput
• Manage the flow

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How long does a scan take?

• Multiple queues
• Multiple slot types
• arthrogram
• thorax with contrast
• spine
• thorax
• Eliminate the carve-out

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Build new CT templates
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Monitor progress
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Matrix Allocation Step 1Draw a matrix
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Step 2Fill in the matrix
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Step 3Establish clinical care groups
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Step 3Allocate patients
Patient with condition 4
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(No Transcript)
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Scheduling

• You cannot schedule your way out of a capacity
  problem...

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What doesnt scheduling do?

• Solve problems of a mismatch of capacity and
  demand
• Deal with unusual events

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Define capacity and demand
Scheduling will not resolve this problem
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The solutions

• Increase Capacity to match Demand
• Decrease Demand to match Capacity
• There are no other options!

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Define capacity and demand
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An example of scheduling the bottleneck
Flexi-sigmoidoscopy
Identify the - number of people - number of
rooms - pieces of equipment available
2 loos for preparation 1 theatre for scoping 1
nurse for preparation 1 scoper for scoping and
writing notes 4 recovery chairs for recovering
balance
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Line up the templates
Wasted time Only 4 patients done
What is the constraint? (defining capacity) What
is the bottleneck? (current limit on activity)
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What solutions can you suggest?

• Add another endoscopy suite

Add more toilets
Get patients to do the bowel prep at home
J
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Fix the loos and set new templates
11 patients done in the same time!
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What are the risks?

• Some patients will not come fully prepared
• They will have to be rescheduled to another day
  or at the end of the clinic
• Do not schedule to 100 utilisation of the
  scarcest resource
• Do you want to fly in a plane that is scheduled
  to use 99 of the available fuel to get to its
  destination?
• Remember that capacity is 80 of the fluctuation
  in demand

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The road to ruin
Capacity plans and contracts based on average
past activity
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The road to financial health
Capacity planning and contracts based on
variation in demand
Staff capacity to reduce variation in capacity