1. Managing Variation, Understanding the Effects of Carve-out, Scheduling and Flow

2. How do we manage variation in demand? Delay Forced booking Carved out capacity

3. Carve-out can be… Huge Number of doctors Number of appointment types 2 week wait Urgent Soon Routine Urgent follow-up Routine follow-up Secretary Post-op Thousands of combinations It is impossible to balance the queues

4. The size of the carve out Number of specialists 432 Surgeon 1 432 Physician 1 5 Radiologist Number of appointment types Flexi-sig Colonoscopy ERCP OGD urgent soon routine urgent soon routine urgent soon x x x x x x xx x x x x x xx xx x x xxxx x x x x x xxxx xxx xx xx xxx xxxx xxxxxxx x xxxxx x x x x x x x xx x x x xx 73 queues

5. Server Queue type AQueue type B

6. Is all carve-out bad? Capacity for urgent cases (prioritisation of patients) Subspecialisation The issue is not to eliminate all carve-out, but rather to eliminate unnecessary carve-out and reduce the impact of carve-out we can’t eliminate

7. Terms Carve-out When the flow of one group of patients is improved at one bottleneck at the expense of another group of patients Streaming or segmentation Separation of the process of care along the whole pathway for one group of patients to improve overall flow but not at the expense of other groups of patients

8. Analogy of segmentation and flow: traffic flow on motorway Slow lane 50 mph Middle lane 70 mph Fast lane 90 mph All vehicles keep to same speed in allocated lane and all progress according to their need

9. What happens when lorry moves into middle lane at 55 mph? Slow lane 50 mph Middle lane 70 mph Fast lane 90 mph backlog of traffic actual consequences are not seen at point of bottleneck flow rates compromised few needs met

10. Carve-out Carve-out interrupts the flow of patients and keeps them waiting (traffic lights) Concrete barriers so traffic can’t move into ‘spare space’ Can’t match demand and capacity Queues galore

11. When is it carve-out? When ring-fencing resources for one group reduces resource available for another group How can we tell whether the problem is carve- out or capacity?

12. Demand exceeds capacity If Demand > Activity or Capacity Numbers waiting will go up Waiting times will go up

13. Carve out and churn Number waiting is constant over time But waiting times may not be If Demand = Activity urgent routine “Skimming off the froth”

14. Variation and carve-out Variation helps cause the waiting list Carve out makes it worse So what are we to do?

15. Match capacity and demand! Set the maximum waiting time to the time the most urgent referral can afford to wait –Do today’s work today –Do this week’s work this week –Do this month’s work this month

16. What do we want to achieve? Maximise Throughput Treat the maximum number of patients with the minimum amount of waiting How? By keeping every machine and person working flat out Utilisation = efficiency Sweat the assets! Wrong

17. Flow We need to optimise the whole process - not each individual step Don’t maximise utilisation, maximise throughput Manage the flow

18. How long does a scan take? Multiple queues Multiple slot types »arthrogram »thorax with contrast »spine »thorax Eliminate the carve-out

19. Build new CT templates Prepare patient Scan patient Get off scanner Report Films Type Report 20 minutes - “Quickie” Prepare patient Scan patient Scan patient Contrast Get off scanner Report Films Type Report 40 minutes - “Longie”

20. Monitor progress

21. Matrix Allocation: Step 1 Draw a matrix Consultant CCConsultant BB Consultant AAConsultant DD Consultant EE Consultant FF Condition 6 Condition 5 Condition 4 Condition 3 Condition 2 Condition 1

22. Step 2 Fill in the matrix Consultant CCConsultant BB Consultant AA Consultant DDConsultant EEConsultant FF Condition 6 Condition 5 Condition 4 Condition 3 Condition 2 Condition 1 x x xx x x xxxx xx Ensure all conditions have at least one consultant xxx xxx

23. Step 3 Establish clinical care groups Consultant CCConsultant BB Consultant AA Consultant DDConsultant EEConsultant FF Condition 6 Condition 5 Condition 4 Condition 3 Condition 2 Condition 1 x x xx x x xxxx xx xxx xxx ccg 1 ccg 2

24. Step 3 Allocate patients Patient with condition 4 Consultant CCConsultant BB Consultant AA Consultant DDConsultant EE Consultant FF Clinical care group 4

26. Scheduling You cannot schedule your way out of a capacity problem...

27. What doesn’t scheduling do? Solve problems of a mismatch of capacity and demand Deal with unusual events

28. Define capacity and demand: Capacity: 180 patients per month Activity: 160 patients per month Demand: 200 patients per month Backlog: 350 patients Scheduling will not resolve this problem

29. The solutions: Increase Capacity to match Demand Decrease Demand to match Capacity There are no other options!

30. Define capacity and demand: Capacity: 240 patients per month Activity: 160 patients per month Demand: 200 patients per month Backlog: 350 patients But it might solve this one...

31. An example of scheduling the bottleneck Prepare bowel Prepare patient Scope Write notes Recover balance Patient Nurse Endoscopist Identify the - number of people - number of rooms - pieces of equipment available 2 loos for preparation 1 theatre for scoping 1 nurse for preparation 1 scoper for scoping and writing notes 4 recovery chairs for recovering balance Flexi-sigmoidoscopy

32. Line up the templates Only 1 endoscopist, so cannot start 2nd patient till endoscopist free Only 2 loos, so cannot start the third patient until a loo is free! What is the constraint? (defining capacity) What is the bottleneck? (current limit on activity) endoscopist can’t start till late Wasted time Only 4 patients done

33. What solutions can you suggest? Add another endoscopy suite Add more toilets Get patients to do the bowel prep at home

34. Fix the loos and set new templates… 11 patients done in the same time! Appointment times set so that the endoscopist starts on time Schedule the template around the constraint

35. What are the risks? Some patients will not come fully prepared They will have to be rescheduled to another day or at the end of the clinic Do not schedule to 100% utilisation of the scarcest resource Do you want to fly in a plane that is scheduled to use 99% of the available fuel to get to its destination? Remember that capacity is 80% of the fluctuation in demand

36. The road to ruin: Capacity plans and contracts based on average past activity Fail to deliver required activity Income less than expected Cost cutting initiatives Fail to account for variation in demand Reduces effective capacity Guarantee waiting times beyond emergency and elective targets Increase staff overtime & waiting list initiatives Increased costs Increased variations in capacity Fail to account for variation in capacity +

37. The road to financial health Capacity planning and contracts based on variation in demand Income guaranteedCosts controlled increases productivity Required activity guaranteed No waiting beyond emergency or elective targets Staff capacity to reduce variation in capacity