Oxford Radcliffe NHS Trust A Practical Approach To Improving patient flow using The Theory of Constraints Oxford Radcliffe NHS Trust

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

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

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

Rate Limiting Step – Weakest Link Referral OPD Waiting list Pre – assessment surgery OPD 100 60 60 50 25 12

Types Of Constraint Find The rate limiting factor: Physical bottleneck – a capacity limited resource Thinking Constraint – ‘We’ve always done it like that’ Policy Constraint – an organisational policy whether written or believed

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.

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

TOC as a Generic Tool Principles may be applied to any whole System Gynaecology PND & Ultrasound MaxilloFacial/ Orthodontics Urology Finance Horton General Hospital

Case Study – Horton General District general hospital = 240beds 2000 –2001 Long Trolley Waits High Cancellation of electives due to”no beds available”.

Introduction Of TOC April 2001 – Capacity group formed April 2001 – TOC Workshop for key stakeholders May 2001 – System mapping and analysis

HGH – Identify the Constraint Medicine Discharge A&E Treatment PCT Surgery Social Care Waiting List Discharge+ Trauma & Ortho

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 A&E. Location of Day case patients

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

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

Information 25% of admissions through A&E stayed 24 hours or less – of those: - 25% non specific chest pain - 18% self harm Minimal day case activity found in inpatient areas. PCT – A&E used appropriately by GP’s

Information V Anecdote Many decisions about waiting times are based on anecdote not fact!

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

5 Steps of TOC Step 4 – Elevate the constraint Discharge Beds - increase in capacity New build for Emergency transfer Beds Step 5 – Go Back

Results so far…. Trolley waits reduced Over 80% of patients are admitted within 4 hours of decision to admit in A&E Number of elective cancellations reduced.

Results

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

Discharge beds

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.

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.