Transcript Document

Diagnostics and Constraints
Theory
Marcus Kennedy
Clinical Lead
Patient Flow Collaborative
4th May
Department of Human Services
From project to habit…
• Themes of today:
– Reinforcing what we have learnt
– Showcasing improvements
– Making these effective methods part of
every day business
A story
• Hospital x identified an ‘elective surgical
throughput’ value stream
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Access problems
Waiting list blow outs
Admission systems chaotic
Theatre bookings whimsical
Not meeting targets
Losing bonus dollars
Losing surgeons
HELP !!!
PFC
Why Multidimensional?
A. Because this was the NHS
way?
B. Because Jenny Bartlett said
so?
C. Because this way we could
see and appreciate whole
systems from all
perspectives:
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Organisational
Patient
Workers
To avoid tunnel vision and
myths
Theory of Constraints
…like a chain with its weakest link, in any
complex system at any point in time, there is
most often only one aspect of that system
that is limiting its ability to achieve more of
its goal. For that system to attain any
significant improvement, that constraint must
be identified and the whole system must be
managed with it in mind…
The Five Focusing Steps of the
Theory of Constraints (TOC)
– Identify the system constraint.
• Although a system will have many processes, few will represent
a constraint to the overall system. The more complex the
system, the more likely it is that there will be a single, overall
bottleneck
– Get the most out of the constraint
• since it determines system throughput. The entire value of the
system is represented by what flows through the bottleneck. For
instance, you would want to keep the bottleneck working all the
time, since your whole system is idle if the bottleneck is idle
– Support the constraint
• by making it only do work that cannot be done elsewhere
– Elevate it
• within the system so that all other parts work to help it
– Return to step 1
• because a different process may have become the constraint
Constraint Theory
Hospital ‘x’ Identified
Constraints
1. Discharge incoordination due to registrar OR
commitments
2. Booking system organisation
3. Availability of fluoroscopy in OR
“Lean” approach
• Understand Customers and
what they value
• Define the internal value
stream
• Eliminate waste, make
information & products flow,
pulled by customer needs
• Extend the definition of value
outside your own company
• Continually aim for perfection
Terry Young, Sally Brailsford, Con Connell, Ruth Davies, Paul Harper and Jonathan H
Klein, Using industrial processes to improve patient care BMJ 2004;328;162164
Understanding the “wastes”
of ‘lean’
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Overproduction
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Defects
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Unnecessary information or inventory
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Inappropriate processing
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Excessive transportation
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Waiting
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Unnecessary motion
– Producing too much too soon, resulting in poor flow of information or the deliverable
and excess
– Frequent errors in paperwork, data and information, product quality problems, or poor
delivery performance
– Excessive storage and delay of information or products, resulting in excessive cost and
poor customer service
– Going about work processes with the wrong set of tools, procedures of systems, often
when a simpler approach would have been more effective
– Excessive movement of people, information or material, resulting in poor flow and long
lead times
– Long periods of inactivity for people, information or material, resulting in poor flow and
long lead times
– Poor workplace organization, resulting in poor ergonomics, eg excessive bending or
stretching and frequently lost items
I’m a textbook hero !
Solution to key constraint
• Event driven discharge
• Patients went home .6 days
earlier
• Capacity improved
• Therefore inspired by sweet
success the team moved on
and tackled the second
constraint
– Booking system organisation
Booking system
improvements
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Streamlined
Removed duplication
Single assessments
Removed paperwork
Automated messaging and contacts /
reminders
Impact = -2730 C
Why is it so?
Shifting Constraints
• Now that event driven discharge allowed
shorter LOS
• Allied health services required on the day of
discharge were unable to meet demands
Systems are dynamic beasts
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Initial constraint analysis
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Post intervention constraint analysis
Complex Systems
• We deal with complex,
multiply intersecting
and interdependent
systems
• Not linear independent
production lines
Chaos Theory
• The relationships within
these chaotic systems are
not always initially clear
• Beware of assumptions
(aka myths &
preconceptions) : these
are the inherent flaws of
many of our less effective
previous strategies
– Continuous measurement
and analysis
– Continuous Whole system
orientation
Repeat analysis
• Repeat diagnostics / constraint analysis
– Tailor
– Refine
– Embed methodology
• Actively revisit Lean Methodology
interventions
– Targeted at constraints
– Beware fanatical / untargeted application in a
complex / chaotic system
– Intervention theme not a new organisational
religion
Project to System
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Do something or nothing will happen
Current bed management + PFC = way to go
Executive links
Redefine TOR
Actively build in Constraint Theory & Lean
Thinking
• Celebrate achievements
Data:
• Selected (refined) data presentation of
previous month and week
• Forecast data presentation for next week
(based on historical/previous yr data and
known current activity & threats)
Strategy:
• Current Flow Improvement Strategies
(presented in action table)
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achievements since last meeting
challenges encountered in progressing plan
known threats for next week
plans for next week
actions points
Policy and Procedure:
• review of flow policy and process breaches
over the last week
• actions defined
Retain Methodological
Context
• Review of Constraint Table (~Fortnightly)
– Lists Organisational Value Streams, with identified
key constraints per stream and action priorities.
– Identifies next actions re improvement and allows
forward planning of implementations.
– Drives knowledge of constraint theory and lean
thinking methodologies
Anticipation
• Review of Threats (~Monthly)
– The month ahead is assessed with regard to
perceived threats to patient flow eg public
holidays, staff changeovers, public events,
conferences and other leave, known infrastructure
changes, shutdowns or decrease in performance.
New Hospital Access Targets
• Tens of Million$
– “Matters” to the base budget
• Achievement
– Go harder and faster
– Do something different
– Those that have already implemented change are
advantaged
12 months down the track:
•Are expectations (culture) of flow different?
•Are systems changing to achieve this?
•Have we achieved all we needed to?
•Have we got the right tools?
•Have we learnt to use them optimally?
•Will we get there?
Questions