Managing patient flow using time buffers

Transcription

1 Managing patient flow using time buffers Presented by: Alex Knight, QFI Consulting, UK Roy Stratton, Nottingham Business School, NTU, UK Date: June TOCICO. All rights reserved. 1

2 Presentation structure Achievements so far (Alex) Applying flow concepts to health and social care (Roy) How and why Time Buffer Management (TBM) works in health and social care? How does TBM relate to kanban and lean healthcare? Deeper insights (Alex) 2

3 Health and social care system - the chain of activities Home Home Home Home GP referrals Electives Social & Health Social & Health Social & Health Ambulances Minors ED MAU Acute Rehab Residential & Nursing Outpatients Social & Health Emergency Room Acute Rehabilitation Hospital Medical Assessment Unit Social & Health Residential & Nursing Home 3

4 Headline user claims I don t think anybody could have anticipated the difference it actually made to our length of stay. It s been profound. Within two months we had halved our average length of stay. It has been a really positive initiative and I wouldn t like to let go of it now. Lesley Dobson, Senior Sister, Derbyshire Community Hospitals, England I think we ve achieved more than I anticipated far more quickly than I anticipated. Lynn Walshaw, Head of Urgent and In-patient Services, Derbyshire Community Hospitals, England We have been able to move from one of the worst performing Trusts in England to one of the top performing. By applying 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, Barnet & Chase Farm Hospitals NHS Trust, England 4

5 Headline user claims The application of TOC has helped us to reduce our length of stay by up to 23% in one of our hospitals, but the real benefits from QFI-Jonah are around improving how we deliver care to our patients through better planning and coordination of their care - ultimately it's about recognising that patients should go home as quickly and safely as possible. CEO TOC has been applied to improved patient flow in A&E, assessment units, and discharge planning. This has resulted in a sustained reduction in medical length of stay from 8.6 to 6.3 days (>25%). Released bed capacity supported the achievement of the 18 week GP referral to treatment target, a year ahead of schedule. Director of Governance and Nursing. We had a two-day meeting with Alex Knight and at some point in the second day I realised that 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, St Maartenskliniek, Nijmegen, The Netherlands 5

6 Results so far Please visit 6

7 Presentation structure Achievements so far (Alex) Applying flow concepts to health and social care (ROY) How and why Time Buffer Management (TBM) works in health and social care? How does TBM relate to the kanban and lean healthcare? Deeper insights (Alex) 7

8 Standing on the shoulders of giants When Taiichi Ohno developed TPS, he didn t do it in the abstract; he developed it for his company. It is no wonder that the powerful application that Ohno developed might not work in fundamentally different production environments. (Goldratt, 2008) DBR and CCPM are likewise built on assumptions that need to be conceptually translated to applications in health and social care. 8

9 Generic applications of Time Buffer Management (TBM) Two generic applications of the time buffer concept Simplified DBR buffer (manufacturing/operations) Buffer: Planned process time touch time is insignificant (or unknown). Critical Chain Project Management buffer (project) Buffer: Planned processing time touch time is significant and known. 9

10 Health and social care system - the chain of activities Home Home Home Home GP referrals Electives Social & Health Social & Health Social & Health Ambulances Minors ED MAU Acute Rehab Residential & Nursing Outpatients Emergency Room Acute Rehabilitation Hospital Medical Assessment Unit Social & Health Residential & Nursing Home Access targets: ED=4 hrs 10 Social & Health Elective surgery=18 weeks

11 SDBR buffer management simplification in healthcare applications Split the 4 hour process into 3 zones: green, amber, red. Rope 4 hours Drum patient arrival Actively manage patients in the amber zone to avoid them moving into the red zone. Patients in the Red/Black zone to be expedited through the remaining steps in the system. 11

12 Health and social care system - the chain of activities Home Home Home Home GP referrals Electives Social & Health Social & Health Social & Health Ambulances Minors ED MAU Acute Rehab Residential & Nursing Outpatients Emergency Room Acute Rehabilitation Hospital Medical Assessment Unit Social & Health Residential & Nursing Home Access targets: ED=4 hrs 12 Social & Health Elective surgery=18 weeks

13 Healthcare Discharge Buffer Management - a hybrid development Patient Arrives Time now Planned Date of Discharge 50% 25% 25% Continuing Form (3 days) Discharge tasks Occupational Therapy (2 days) Physiotherapy (1.5 days) Remaining duration reviews and buffer meetings 13

14 Healthcare Discharge Buffer Management - a hybrid development Patient Arrives Time now Planned Date of Discharge 50% 25% 25% Continuing Form (3 days) Occupational Therapy (2 days) Physiotherapy (2 days) The current time is in the green zone but projected to be in the red due to an activity duration of 3 days Remaining duration reviews and buffer meetings 14

15 QFI Discharge Jonah - top delay reasons by resource 15

16 The weekly buffer meetings Multidisciplinary team Maximum 1 hour Review the top buffer penetrating patients Identify and agree recovery actions Record reasons of buffer penetration for future system improvement 16

17 QFI Jonah applications now run in emergency, discharge, elective, community, mental health, day surgery, home care and outpatients HEALTH AND SOCIAL CARE SYSTEM - The chain of activities Home Home Home GP referrals Ambulances Minors Electives B U F F E R M A N A G E M E N T Home Social & Health M A B N U A A&E F G Acute CH F E R E M E N T Social & Health Social & Health Residential & Nursing Social & Health Accident & Emergency Home Acute Social and Health Community Hospital Residential & Nursing 17

18 Buffer management functions relating to health and social care Prioritise the flow of work (buffer penetration) A&E UK fixed lead time (4 hours) Complicated by planned discharge dates changing Identify when to Expedite potential delays Respond to individual patient red zone penetration Signals when there is a need to Escalate increased capacity Respond to significant and growing red zone penetration Identify and target main sources of delay for Eradication Pareto analysis causes and target improvement activities 18

19 Limitations Pareto analysis is only a crude starting point for analysis of causes of delay. True causes of delay are often identified through a deeper understanding of common causes of delay across the system as a whole. SDBR - which resource is most often causing the most delay to the most patients across the system as a whole? TBM - which short sequence of tasks and resources most often cause the most delay across the system as a whole? 19

20 Presentation structure Achievements so far (Alex) Applying flow concepts to health and social care (ROY) How and why Time Buffer Management (TBM) works in health and social care? How does TBM relate to the kanban and lean healthcare? Deeper insights (Alex) 20

21 Can kaizen blitz replace the role of kanban in lean healthcare? Lean kaizen events [rapid improvement events] in healthcare are often not strategically focused as suggested by Dan Jones in his Lean Enterprise (August 08) news letter. Improvement is not so easy to sustain With only loose direction from top management it is difficult to trace the results from these islands of improvement and no one checks. We recently did an assessment of a hospital that had done 93 kaizen events. The success rate was less than 20% and none of these had impacted the core A&E process that really kept the CE awake at night (Jones, 2008) 21

22 Kanban was central to the TPS The traditional means of strategically focusing continuous improvement in Ohno s Toyota Production System is through kanban control (Ohno, 1988: 30). Kanban is a way to achieve just-in-time; its purpose is justin-time. Based on this, production workers start work by themselves, and make their own decisions concerning overtime. The kanban system also makes clear what must be done by managers and supervisors. This unquestionably promotes improvement in both work and equipment. (Ohno, 1988:29) 22

23 How do the TPS kanban functions effectively apply in healthcare? The seminal work of TPS and lean is the emphasis on flow Reduction of wasteful variation Continuous improvement In reality practicing these rules [the six rules of kanban] means nothing less than adopting the Toyota Production System as the management system of the whole company. (Ohno, 1988:41) Have lean applications in healthcare fully exploited this to date? 23

24 Kanban illustration 24

25 Kanban Functions of kanban 1. Provides pic k-up or transm i ssion inform ation. 2. Provides production inform ation. 3. Prevents over production and excessive transport. 4. Serves as a work order attac hed to goods. 5. Prevents defective products by identifying the process m aking the defec tives. 6. Reveals exis ting problem s and m ai ntains inventory control. Kanban rules of use 1. Later process picks up the number of items indicated by the k anban at the earlier process. 2. E arlier process produces items in the quantity and sequence indicated by the kanban. 3. N o item s are m ade or transported without a k anban. 4. A lways attached a kanban to the goods. 5. D efective products are not sent on to the s ubsequent proces s. The result is 100% defect free goods. 6. R educing the num ber of k anban increases the ir sesitivity. The functions and rules of kanban (sourc e: Ohno, 1988: 30) 25

26 Interpreting Ohno s Functions Functions/rules 1, 2 and 4 are concerned with the transfer and production of information associated with standard predefined specifications, routings and transfer data. Function 3 is vital to the lean focus on Just-in-Time production and ensuring inventory between each work centre is kept to a predefined level. Function 5 ensures the source of defects is made immediately visible, therefore ensuring rapid problem identification and resolution. Function 6 enforces continuous improvement. The number of kanbans in the replenishment cycle represents the inventory currently needed to ensure reliable supply. Reducing the number of kanbans reduces the buffer inventory and therefore time, so making the system more sensitive to problems in the drive towards perfection. 26

27 Time Buffer Management (TBM) and Kanban functional comparison TBM Functions Kanban Functions Prioritize Provides relative priority based on planned completion time rather than intermediate processing steps and inventory. Controls RM release Expedite Proactive time based signalling of potentially late completion (red zone penetration). Escalate Proactive time based signalling of growing levels of expediting Eradication Targeting the repeated causes of expediting (red zone penetration) reduces the need for time buffers and improves flow F1 Pull intermediate inventory F2 Pre-planned quantity and routing sequence F3 Prevents over production at each stage F4 Predefined works order data F5 Quality (variability in the process) signals immediate action. F6 Reducing the number of kanbans (inventory) is used to highlights causes of disruption to flow. 27

28 Kanban and TBM assumptions Kanban assumes: Predefined process steps Buffering is based on time and held at each processing step Process delays (quality problems) are not passed on to the next process Level scheduling Continuous improvement is encouraged through reducing inventory to expose problems that are then targeted. TBM assumes: No predefined processing steps Buffering is based on time and pooled Delays are only expedited when they threaten delivery Demand may vary triggering (timely) escalation Continuous improvement is enabled by targeting the causes of delay (e.g. red zone penetration) then reducing the time buffer. 28

29 Presentation structure Achievements so far (Alex) Applying flow concepts to health and social care (Roy) How and why Time Buffer Management (TBM) works in health and social care? How does TBM relate to the kanban and lean healthcare? Deeper insights (Alex) 29

30 Deeper insights: well not really! After continuously developing and implementing these concepts in over twenty hospitals in UK, Holland and USA what have we learnt: When we follow the TOC based process we have developed we get a major breakthrough and ongoing improvement. 30

31 The QFI Strategy and Tactics tree for health and social care top level Achieving a breakthrough in health and social care Achieving Consensus Operational Breakthroughs Finance & Measures Market Breakthroughs Sustainability A logic and evidenced based approach to achieving consensus Unprecedented improvement in quality and timeliness of care Managing in the throughput world Revenue grows faster than any increase in medical cost Sustaining the improvement 31

32 The QFI Strategy and Tactics tree for health and social care top level Achieving a breakthrough in health and social care Achieving When Operational we don t Finance & follow Market Sustainability Consensus Breakthroughs Measures Breakthroughs the process we do not get a major A logic and Unprecedented evidenced breakthrough based improvement in Managing in the Revenue grows Sustaining the approach to quality and throughput nor world any faster significant than any improvement achieving timeliness of care increase in medical consensus cost improvement! 32

33 Deeper insights what does a major breakthrough look like? A major breakthrough is where we get an irrefutable and unprecedented leap in performance and a simultaneous unprecedented reduction in variability in the measure of performance. Profit, throughput or cash flow Length of stay, waiting times, access times Delayed patient days, on time treatment Patient and staff satisfaction If we resolve constraints that limit the throughput of the system or that govern the behaviour of the system surely this is an inevitable outcome? 33

34 Quotes from recent implementations Within two months we had halved our average length of stay. I think we ve achieved more than I anticipated far more quickly than I anticipated. This has resulted in a sustained reduction in medical length of stay from 8.6 to 6.3 days (>25%). Released bed capacity, supported the achievement of the 18 week GP referral to treatment target a year ahead of schedule. Results were achieved almost overnight despite repeated failure prior to the QFI-Jonah implementation. 34

35 Why do I raise these examples? When a methodology is becoming the main way then society finds a number of ways of integrating it into its understanding of the world: The results are not conclusive enough yet... The results appear valid in that environment but our environment is different... The results are similar to results we see from other methodologies... What about TOC becoming a main way? What are our responsibilities as TOC professionals? 35

36 Respect for similarities and respect for differences Ensure we relentlessly publish, with full academic support, the results we have achieved. Ensure we are clear if we have achieved a true breakthrough or not. If we have achieved a breakthrough we should expect to see a simultaneous and unprecedented jump in performance and reduction in variation almost immediately. This is at the core of TOC. Be explicit where we feel the breakthrough has been achieved through the Theory of Constraints or where it has been achieved through a combination of efforts. If there have been a combination of efforts then be careful to ensure we understand why the joint efforts have delivered the results. TOC and Lean Thinking/Kanban should be respected for their similarities and their differences. Trying to falsely amalgamate these methodologies is disrespectful to both and doing neither a favour. Selling TOC as some sort of subset of Lean is TOoCLEAN by far and a big mistake in the journey of making TOC the main way. 36

37 Conclusions Achieving a true breakthrough in performance is when one sees an unprecedented and simultaneous increase in performance and reduction in variation of the system as a whole. The functional elements of TBM and kanban are designed for very different levels of instability. Time buffer management clearly fits unstable patient flow environments. Respecting the similarities and differences of these methodologies is key to the ongoing development of processes of improvement. 37

38 References Goldratt, E.M., Standing on the Shoulders of Giants Production concepts versus production applications - The Hitachi Tool Engineering example. Goldratt Consulting Jones, T.J., Lean Enterprise Academy News Letter 18 August, available at (accessed 13 November 2008). Ohno, T., The Toyota Production System; Beyond Large- Scale Production. Productivity, Portland, OR. Stratton, R.and Knight, A., Applying Manufacturing Flow Theory to Health and Social Management. Proceedings of the 21st Annual Production Operations Management Conference. Vancouver, Canada, 7th -11th May. Stratton R. and Knight A., Managing Patient Flow using Time Buffers. Journal of Manufacturing Technology Management, accepted Dec 09 38

39 About Alex Knight Alex Knight is a founding partner of QFI Consulting. Prior to this Alex was the managing director of Ashridge Consulting Group) and a board director of Ashridge. Alex was the first chief executive of Goldratt Consulting Ltd), helping to steer it through its formative years as a global organisation. Alex has led many TOC implementations in healthcare organisations in the UK, Holland, the United States and Australia. He has also provided strategic consulting for the National Childbirth Trust, the Linney Group, Samworth Brothers, the Robert Gordon University, Zurich and NHSBT, to name just a few. Alex plays lead guitar in a rock band called One 2 Many. 39

40 About About Roy Stratton Roy is based in the UK and is Principal Lecturer in Operations and Supply Chain Management at Nottingham Business School, Nottingham Trent University where he is actively involved teaching, research and consultancy. He is Director of the Centre for Performance Management and Lean Leadership and Programme Manager of the MSc Theory of Constraints (Health and social Management), delivered in collaboration with QFI Consulting. Previously, Roy worked for Rolls Royce Aero Engines in an internal consultancy role and has since been actively involved in a wide range of industry-based and government funded knowledge transfer research projects. He has published widely in both professional and academic journals. Roy is a Chartered Engineeer (MI Mech E) and has been awarded a BSc in Mechanical Engineering (Nottingham), an MSc in Manufacturing System Engineering (Warwick), and a PhD in Supply Chain Management (Nottingham Trent). He is certified in all TOC ICO fields, a member of the Goldratt Schools faculty and the current chair of the newly formed TOC ICO healthcare SIG. 40