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

2. 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

3. 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

4. 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

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

6. 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

7. 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.

8. 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

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

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

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

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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 5 Steps of TOC Step 4 – Elevate the constraint
Discharge Beds - increase in capacity
New build for Emergency transfer Beds
Step 5 – Go Back

20. 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.

21. Results

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

23. Discharge beds

24. 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.

25. 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.