1. Allied Healthcare Professions Service Improvement Projects Regional Event Process and Service Redesign Resource Pack

2. 2 Company Confidential Aims of the session understand principles and history of process redesign introduce tools and techniques to map and fully understand processes introduce a range of tools and techniques to use in redesigning services

3. 3 Company Confidential W Shewhart – Statistical Process Control, PDSA W E Deming – System of Profound Knowledge 20’s 50’s (Toyota) Lean thinking (Motorola) 6 Sigma E Goldratt - Theory of Constraints M Hammer - Business Process Re- engineering Total Quality Management 90’s 30-40 70’s 80’s Since the 1980s: Adapt, not adopt in the NHS Evolution of improvement

4. 4 Company Confidential Any improvement is a change –not every change is an improvement –but we cannot improve something unless we change it Eliyahu Goldratt Goldratt E (1990) Theory of Constraints, North River Press, Massachusetts Theory of constraints

5. 5 Company Confidential What does process re-design give us? optimises flow by eliminating waste and bottlenecks – things run smoothly and to plan therefore maximises outputs for any given resource this minimises cost per case improves patient’s experience – fewer hold ups, delays and unexpected glitches improves staff morale – things run more smoothly, start and finish when planned, fewer frustrations

6. 6 Company Confidential NO2704-202 Process redesign Eliminate waste Linked processes Match capacity and demand Reduce batching Process mapping

7. 7 Company Confidential A process map

8. 8 Company Confidential NO2704-202 Process mapping Every system is perfectly designed to get the results it achieves

9. 9 Company Confidential NO2704-202 How to build a process map get everyone involved in delivering the process together choose an (independent) facilitator to run the session agree scope - start and end points have plenty of flipchart (brown paper) and post it notes handy map at a high level to begin with focus on the process steps – don’t jump to solutions! delve in to detailed areas if needed ( a separate process map may be required) have fun but gain a consensus and agree further actions do you want to practice?

10. 10 Company Confidential NO2704-202 Benefits of process mapping simple exercise – easy, creative and FUN powerful way for MDT understand real problems from patient (customer) perspective identifies opportunities for improvement provides forum for innovation Interactive end product, visual and owned

11. 11 Company Confidential Symptoms and examples of ‘waste’ WasteSymptomExample Mistakes  clinical incident  complaints  multiple checking systems  patient with more than one PAS number  post-operative wound infection  drug error  equipment failure  patient outlying on ‘wrong’ ward Uncoordinated activity  tests undertaken before they are needed and when they are not unnecessary  bed requested ‘just in case’ Stock  poor ability to respond to problems  increased need for storage space  high level of work in progress  high volume of stock in departments  high level of patients in the process, sitting around waiting Transportation  movement of documents, materials and patients  ambulance conveys patient with minor injury to A&E department  patient outlying in wrong ward  specimens transported to centralised laboratory for processing Unnecessary motion  excessive walking  poor layout of working environment Inappropriate processing  high variation  batching  duplication  patients seen by many healthcare professionals when one would do  multiple data entry on information systems that do not communicate  patient details recorded on A&E ‘white boards’

12. 12 Company Confidential Calculating value added 5 3 5 2012035 Total Time = 188 TIME: Value added time = 13 Total Steps = 20 Steps: Value adding steps = 3 s1 s3 s1 s4 s2 s9

13. Patient has cardiac catheter 1 Secretary types letter 7 Letter dictated to surgeon 2 Tape to ward clerk 3 Tape sent to post room CHH 4 Tape sent to post room HR 5 Tape sent to secretary at HR 6 Secretary request angiogram 14a Patient seen in clinic 19 Letter to surgeon 14 Letter to secretary for OPD 15 Letter to post room CHH 16 Letter to appoint- ments 17 Letter sent to patient 18 Radio- grapher finds angiogram 15a Patient put on waiting list 20 Angiogra m given to porter 16a Angiogra m delivered to secretary 17a Angiogra m reviewed by surgeon 18a Arteries suitable for surgery 19a Surgeon considers patient suitable 20a Letter delivered to secretary 13 Letter to doctor for signature 8 Letter sent to post room CHH 12 Letter sent to post room HR 11 Letter returned to secretary 10 Letter signed 9 Process map for cardiac referral

14. Simplified process Patient has angiogram 1 Patient seen in clinic 6 Letter and angiogram delivered to secretary 4 Data input into computer 2 Secretary make OPD appointment 5 Angiogram tape 7 Print out data as referral letter 3

15. 15 Company Confidential Batching a key reason why setting the pace and achieving smooth flow is very difficult batching is where multiple patients are processed at the same time eg assessment by medical on-call in A&E, ward rounds, reporting of x-ray results, old style appointment times batching means that patients can only move between stages at the rate at which each batch is processed this means lots of waste in the form of waiting and work-in- progress

16. 16 Company Confidential Activity – Batching Clinical assessment InvestigationsClinical decision Admission 1 every 10 minutes Phlebotomist arrives on the hour and half hour to take blood Results available 30 mins later Med SHO visits every hour on the hour A&E informed beds available at 11am and every 2 hrs thereafter Patient 1 arrives at 8am - how long will they wait at each stage? Patient 2 arrives at 12.25pm - how long will they wait at each stage? Patient 3 arrives at 4.35pm - how long will they wait at each stage?

17. 17 Company Confidential Batching results 2hrs 50 2hrs 25 2hrs 15

18. 18 Company Confidential Batching – Summary identify where batching takes place try and quantify the impact it has on the flow by undertaking the type of exercise we have done which batch has the biggest impact on flow? can you eliminate it (batch size = 1)? if not, what could you reduce the batch size to? use this information to try to influence behavior measure the impact

19. 19 Company Confidential More resources or better use of existing? we often hear… –“what we need is more resources” but what we should be asking is… –are we making best use of existing resources? –is investment in additional resources targeted at the right areas? –are capacity and demand matched? –how should we redesign to match capacity and demand?

20. 20 Company Confidential time Demand Queue Can’t pass unused capacity forward to next week Capacity Average demand = average capacity causes a queue

21. 21 Company Confidential bottleneck –part of a system where the patient flow is obstructed, causing waits and delays constraint –cause of bottleneck, usually a skill or piece of equipment eg patient waits for surgery (bottleneck), constraint might be availability of surgeon or anaesthetist Bottlenecks and constraints

22. 22 Company Confidential Types of bottlenecks process bottlenecks –the step in a process that takes the longest time to complete functional bottlenecks –shared resources, eg radiology, pathology, radiotherapy, physiotherapy “an hour lost at a bottleneck is an hour lost throughout the process…an hour gained at a non-bottleneck is a mirage”……..Eli Goldrat “The Goal” (Theory of Constraints)

23. 23 Company Confidential Managing out bottlenecks measurement to predict and manage –demand and capacity patterns manage the bottleneck –maximise work of bottleneck –checking stage in front of bottleneck –free up expert skill –redistribute work resolve capacity problems at the bottlenecks –increase capacity at the constraint –reduce inappropriate demand

24. 24 Company Confidential Setting the pace processes that feed into each other need to be linked, so that the receiving one can see what’s coming and cope with it Clinical assessment Investi- gations Clinical decision Treat- ment Dis- charge Admi- ssion If 5 patients arrive an hour, how many patients need to move between each step each hour? If 10?

25. 25 Company Confidential Overall coordination Clinical assessment Investi- gations Clinical decision Admi- ssion Treat- ment Dis- charge Flow manager requires visibility of the process as whole flows that have a single individual/team/area responsible for the whole flow from start to finish enable action to be taken quickly

26. 26 Company Confidential Pull don’t push! prevents queues improves flow requires less effort! can reduce process bottlenecks requires courage…just in case seen as a safeguard against variation…..but can actually produce variation patients can provide a pull system – demand driven

27. Lindsay Winterton Mobile 07801 376 011 e-mail: lindsay.winterton@frontlinemc.com