2. Session Outline
• Working definition
• How we have prioritised flow
• How we might want to think about flow in future
• What are the issues – why raise our ambition?
• Celebrating our existing work & what it tells us
• Next Steps
3. Flow
1. a. To move or run smoothly with unbroken continuity, as
in the manner characteristic of a fluid.
1. b. To issue in a stream; pour forth: Sap flowed from the
gash in the tree.
2. To circulate, as the blood in the body.
3. To move with a continual shifting of the component
particles: wheat flowing into the bin; traffic flowing through
the tunnel.
4. Right treatment area
Right time
Right team
Right care
(as efficiently as possible and within available
resources)
6. How we traditionally consider flow
• Access targets and standards (point improvements)
• Evolved from point improvements to pathway
management (unscheduled care / 18 weeks RTT/
cancer/mental health)
• Chunking up strategies and goals for the system (i.e.
elective and unscheduled)
• Focus on improving constraints (delayed discharge)
• Strategies having competing impacts (patient boarding)
• Insufficient emphasis on individual patient experience?
• Insufficient recognition of workforce design on flow and
of improvement and workforce relationship?
7. How we should consider flow?
– Access/equity
– safety issue
– experience
– efficiency
– 20/20 Vision demands on acute services are such that
optimising throughput is critical
– Poor flow and inefficient use of capacity can drive up
costs and may be compromising efficiency in all parts
of the system
8. Efficiency & Productivity Framework SR10
Aim, Objectives & Scope
“To improve the overall quality and efficiency of
NHSScotland while ensuring good value for money
and achieving financial targets.”
Key objectives:
Acute Flow & Capacity work-
• Quality is not compromised, stream formed to support NHS
• NHSScotland will achieve financial Boards to improve/optimise flow
balance over the SR10 period, and to challenge unwarranted
• NHS Boards are supported in variation.
achieving efficiency targets and
improving services, and Productive Opportunity (based on
• Central co-ordination of McKinsey DoH study and applied
support, monitoring, benefits pro-rata up to £300m)
realisation and challenge will be
available to NHS Boards.
9. The Problems of Patient Flow –
Why raise our game?
Marilyn E Rudolph
• Peaks and valleys
• Resource utilisation
• Internal diversion – boarding
• Increases in medical errors
• Delays in patient care
• Boarders and ED diversion (non IP areas)
• Left without being seen
• Decreased throughput = increased costs?
• Increased length of stay
• Staff and patient satisfaction
12. Born this Way? People and Reform
Reform agenda domains Medical Medical General Nurse Nurse
clinicians managers managers managers clinicians
Recognise interconnections Ambivalent Accept Strongly Accept Strongly
between the clinical and accept reject
Resource dimensions of care.
Adopt a perspective that Reject Accept Strongly Accept Ambivalent
balances autonomy with accept
transparent accountability.
Participate in processes that are Strongly reject Strongly Accept Accept Accept
oriented to bring clinical work reject
within the ambit of work
process control.
Accept the multidisciplinary Reject Ambivalent Accept Strongly Accept
and hence team-based nature accept
of clinical service provision.
Peter Diegling
15. Median and 90th Percentile Waits
for IP/DC
Median (days) 90th percentile (days)
120 105
100
Wait (days)
80 63
60
35
40 25
20
0
Ju 8
Ju 9
Ju 0
Ju 1
2
M 8
M 9
M 0
M 1
N 8
N 9
N 0
N 1
-0
-0
-1
-1
-1
-0
-0
-1
-1
l-0
l-0
l-1
l-1
ar
ar
ar
ar
ar
ov
ov
ov
ov
M
Quarter ending
25. NHS Tayside: Exploring Improvements for
Effective Management of Capacity and Demand
• Demand activity calculated for each medical specialty
• Reason code tracker completed by each Specialty to ascertain reasons why
capacity not achieved
• Reason code tracker includes: Patients on EDISON / Patients due for
discharge who are placed out with speciality ward for non clinical reasons /
Awaiting script / Awaiting tests/investigations (state what) / No bed in
receiving hospital
• Improvement methodology applied to tailor improvements to each Specialty
• Development of Capacity and Flow page on staff intranet which has daily
activity info, RAG status for each directorate/CHP, access to escalation plan
and action cards
• Developing a 7 day acute physician delivered service model to ensure
senior clinical decision making at the front door
• Interactive whiteboards with real time information
•
26. NHS Fife Waits
230/ 4,8,12 hrs Add. Capacity
~60 / Boarding
250 31 (52)
A&E
Slow
Ad Unit
Queue
7.7(6.4)
52 (62)
pts/d
Q
Assess.
8.8(6)
Home 49(49) Sp Beds
~46/d pts/d
Improving Flow and Emergency Access Programme
•Work streams = Front Door, Acute Admissions and
Specialty Flow, Community Flow
Q
•Metrics and PDSA‟s in each work stream Q Community Assess.
Assess. Beds/IRT ~20
•Front Door examples –
• Flow 1 and 2 / 4 hours
~18
• Fast track triage (time to 1st assessment)
• Junior check in with Cons (referral rate /
clinical safety)
• Specialty Review (time to specialty review) NH
• Increased Consultant cover at peak times Beds
(overall performance at 4 hours)
15/6/2012
27. NHS Greater Glasgow & Clyde
Management of Inpatient Flow
Glasgow Royal Infirmary
– Creation of Emergency Receiving Complex – patients streamed
directly to the following areas :
• Minor Injury Unit
• ED Majors and Resus
• Medical Assessment Unit – GP referred medical patients go
directly
• Impact of the above has demonstrated a significant
reduction in breachers and in particular breach reason “wait
for bed”
28. NHS Greater Glasgow & Clyde
NHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARY
Note: When choosing board to view, do not choose '(All)' as will double count. Select NHS Scotland as board if
wanting to view Scotland level data. ED 4 Hour Breach Reasons by month: October 2010 - April 2012
800
700
Breach Reason
99 Not Known
600 98 Other reason
08 Major incident
Monthly ED 4 hr Breaches
07 Clinical reason(s)
500 06 Wait for 1st assessment
05B Wait for diagnostics test(s) - awaiting results
05A Wait for diagnostics test(s) - to be performed
05 Wait for diagnostics test(s)
400
04B Wait for initial A&E treatment - to be completed
04A Wait for initial A&E treatment - to commence
04 Wait for initial A&E treatment
300 03C Wait for a specialist - Wait for Mental Health/Psychiatrist
03B Wait for a specialist - Wait for Medical Specialty
03A Wait for a specialist - Wait for Orthopaedics
03 Wait for a specialist
200
02 Wait for transport
01 Wait for bed
100
0 Source: ISD A&E2 datamart Management
May-11
Mar-11
Mar-12
Nov-10
Nov-11
Oct-10
Feb-11
Feb-12
Dec-10
Jan-11
Apr-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Dec-11
Jan-12
Apr-12
information Reports covering October 2010 - April
2012. Data is for management information
purposes only and subject to change.
Month
29. NHS Greater Glasgow & Clyde
Management of Inpatient Flow
Use of Lean methodology
• Three teams configured to work at Western
Infirmary; Royal Alexandra Hospital; Victoria
Infirmary to :
– Improve discharge process with increased number of
beds available before midday
– Improve flow through ED/wards by addressing
relationship issues between Medicine and DME
30. NHS Lothian
• Implementation of Real Time Demand and Capacity Management
(Resar, et al, 2011)
• Estimate of 10-15% in day capacity gains through implementing this
methodology
• Project/Improvement Manager in place, estimate 6 months for
implementation, further 6 for sustainability
• Focus on „Discharge Huddles‟ and change in bed meeting process
– accuracy of predictions
– key issues to „unblock‟
32. Strategies for Managing Patient Flow
S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Key principles:
– System-wide not silos
– Science-based, data-driven
– Right structure before improving micro-processes
– Compliance review and enforcement
• Operations Management
– Critical path – minimise delays
– Queuing theory – mismatch between demand and
resources
– Simulation
33. Natural Variability Artificial Variability
• Random • Non-random
• Predictable • Non-predictable (driven
• Can not be eliminated (or by unknown individual
even reduced) priorities)
• Must be optimally • Should not be
managed managed, must be
identified and eliminated
34. A. N. Other Hospital
• Overcrowded
• Safety?
• Experience?
• Waits/Boarding
35. The Natural Variation The Artificial Variation
Hospital Hospital
– Emergencies only – Electives only
– Queuing theory to decide size – Smooth all admissions and
and staffing discharges
– Run at 80% capacity – Run at 95% capacity
36. Strategies for Managing Patient Flow
S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Artificial Variability
– Inadvertence e.g. LoS in HDU awaiting bed
– Provider scheduling – „dysfunctional scheduling of
elective admissions‟
– Inappropriate management of flows
emergency/elective predictions, complexity
• Effects
„Artificial variability cannot be predicted or managed but
must be investigated and eliminated‟
– Compromised quality of care
– Decreased patient satisfaction
– Decreased staff satisfaction
– Operational inefficiency/ high cost of care
37. Strategies for Managing Patient Flow
S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Variability Methodology
Peaks in scheduled admissions is artificial variability
caused by dysfunctional scheduling of elective admissions
– Identify variability
– Classify as natural or artificial
– Statistical test for randomness
– Quantify – as deviation from ideal expected pattern
– Eliminate/ significantly decrease
– Manage natural variability by stratifying patients
38. Strategies for Managing Patient Flow
S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
• Variability Methodology IHO
– Eliminating variability where you can
– Optimally managing it where you can‟t
– Different types of variability in health care
• Clinical variability – illness and response to treatment
• Flow variability – when
• Professional variability – time taken
39. Strategies for Managing Patient Flow
S,G.Vaswani, M.C.Long, B.Prenney, E,Litvak
Phases
• Separate flows
• Smooth elective and queuing theory to emergencies
• Once optimised estimate resource for system
40. 20/20 A Balanced Flow Hospital
• Flow = Quality
• Separate Flows
• Variation Smoothed
• Real Time Queuing
Theory
• Whole System with
Integrated Community
Teams
41. Intelligent Flow
• Making the flows/processes visible/separating them
• Measurement & balancing measures
• Patient experience & co-design
• Complex adaptive thinking – the whole system
• Counter-intuitive - most variation is in elective care and
is a supply not a demand problem
• Generating the evidence base that poor flow is a patient
safety, efficiency and experience issue
• Sustainable improvement will require a focus on
quality, workforce and governance
43. Key Improvement Messages
• Separate scheduled and unscheduled patient flows
• Eliminate / minimise artificial variability wherever possible
• Assign separate resources for scheduled and unscheduled
patients
• Resources for unscheduled patients should be based on
clinically driven maximum acceptable waiting times – match
capacity to the profile of demand
• Resources for scheduled patients should be based on
maximising patient throughput and minimising unnecessary
waiting
• Only after separation and matching capacity to demand
examine fixed resources
44. Next Steps - 2012
• Acute Flow & Capacity Management workstream
progresses improvement projects and maintains close
links to unscheduled care groups. Overarching
improvement context
• Acute Flow & Capacity Management Programme Board
receives proposals to test/implement a whole systems
approach to flow and capacity planning – August 2012
• HSCMB, QAB and Efficiency Portfolio Board invited to
agree proposals
48. Agenda
• Programme Structure
• High level measures
– What are we trying to improve?
• Patient Flow
– Emergency and Elective
• The constraints
• The policies that need changing
• How to make changes happen
49. Structure for an Improvement
Programme
DH, SHA, Monitor, Health Commission etc.
Board Board
GP GP Flow
Emergency
Planned care
Clinical subspecialties
Medicine
Intermediate care
Surgery
Community hospitals
Paediatrics
A&E Long term care Functional
Ambulance Departments
Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport
HR IT Finance Estates Supplies Support
functions
Seattle Children‟s Hospital
51. Weekly A&E performance & crude death rate
April 2007 to Feb 2011
Dec 07 Dec 08 Dec 09 Dec 10
Foundation
Weekly number Status Non elective
deferred
of A&E breaches death rate
What
happened
In Sept
2009?
Non elective deaths / non elective discharges inc deaths
by Date of ADMISSION Comments?
52. Foundation What
Status happened in
deferred September 2009? Weekly Flow
Cost Quality
Ap 07 to Ap – Jan 11
A&E breaches &
Non elective
deaths / discharges
by date of admission
Palliative
Infection control Care
> %15-64 years
excluded
admissions Adult Non elective Rami
(Rate Adjusted Mortality Index)
(excl paeds, obs & midwifery)
compared to average for peer
group
Open new wards
Recruit Total Pay costs
Agenda for change (elective and non elective)
Comments?
54. What the Warwick and Sheffield teams
learned
• Plot the dots!
– weekly data
– reviewed monthly: Board
• Monthly 2 hour meeting:
– Executives, senior clinicians and Dpt. heads from
across the health & social care system
• Study, Adjust, Plan, Do
– When did the statistically significant changes happen?
– Why?
» What did WE change?
55. Understanding Flow
DH, SHA, Monitor, Health Commission etc.
Board Board
Emergency GP GP Flow
Planned care
Clinical subspecialties
Medicine
Surgery Intermediate care
Paediatrics Community hospitals
A&E Long term care Functional
Ambulance
Departments
Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport
HR IT Finance Estates Supplies Support
functions
56. High Level Emergency System Map
Death
Hospital Community
Ambulance Hospitals
Accident Assessment
and Unit(s)
Specialist Intermediate
GP Emergency Ward Care
(services delivered
in the patient‟s home)
Permanent place of residence
60. Closure of
Foundation Community Hospital
Status
deferred
Sept 2009 Weekly Flow
Cost Quality
Ap 07 to Ap – Jan 11
A&E breaches &
Non elective
deaths / discharges
by date of admission
Palliative
Infection control Care
> %15-64 years
excluded
admissions Adult Non elective Rami
(Rate Adjusted Mortality Index)
(excl paeds, obs & midwifery)
compared to average for peer
group
Open new wards
Recruit Total Pay costs
Agenda for change (elective and non elective)
61. High Level System Map
Death
Hospital Closed 40
Community
beds
Ambulance Hospitals
Sept 2009
Accident Assessment
and Unit(s)
Specialist Intermediate
GP Emergency Ward Care
(services delivered
in the patient‟s home)
Permanent place of residence
Continuing Health Care
funding process changed
Oct 2009
62. Lesson for Boards:
Poor A&E performance is due to poor flow OUT
– Constraints are under our control
63. Lesson for Performance Management
• Plot the dots!
– Trend lines should be removed from Excel
– Statistical Process Control
• Reveals the voice of the process
64. What did we learn?
• Plot the weekly emergency admissions by age group:
• 0 to 15
• 16 to 64
Correlates with the high level patient flows
• 65 to 79
• 80 and plus
• Plot Patients-in-Progress (work-in-progress):
– very sensitive to changes in demand x LOS:
• A&E performance (breaches)
• Midnight bed occupancy
– See later
65. Emergency admissions 80 years +
Confirms that poor flow is NOT due to increased admissions of patients > 80 years
66. High Level Emergency System Map
Death
Hospital Community
Ambulance Hospitals
Accident Assessment
and Unit(s)
Specialist Intermediate
GP Emergency Ward Care
(services delivered
in the patient‟s home)
Permanent place of residence
(0 to15) 16 to 64 65 to 79 80 and plus
years
Warwick
Sheffield: GSM
67. GSM: How Many Bed Nights Do
They Stay?
Pareto of Bed Nights for Home to Home Patients
100%
90%
80%
70%
60%
Cum Freq
50%
40%
30%
20%
10%
0%
0
6
12
18
24
30
36
42
48
54
60
66
72
78
84
90
96
102
108
114
120
126
132
138
144
150
156
164
175
189
205
263
Bed Nights
68. Day to day
Admissions Discharge mismatch
NEL Admission Discharge mismatch
number of NEL patients
admtted and dicharged
80
70
60 Total NEL admissions (NEL
50
40
+ NEL other) 1.
30 Total NEL discharges (NEL
20 + NEL other) Reduce daily
10
0 variation in
discharges
7
07
7
7
07
8
8
08
08
08 00
22 00
29 00
12 00
19 00
20
20
20
20
2
2
2
2
2
2/
2/
2/
2/
2/
1/
1/
1/
1/
/1
/1
/1
/1
/1
/0
/0
/0
/0
01
15
05
26
date
Elective Admission Discharge mismatch
Nubmer of elective patients
admitted and discharged
80
70
60
50
40
EL admissions
2. Smooth
30 EL discharges
20 Variation in
10
0 PLANNED
01/12/2007
08/12/2007
15/12/2007
22/12/2007
29/12/2007
05/01/2008
12/01/2008
19/01/2008
26/01/2008
Elective
Admissions
date
69. In-day mismatch between
Emergency admissions and Specialist capacity
Time of Arrival into A&E Time of Departure out of A&E to Main Hospital
450
400
Patients admitted
when capacity is not
350
300
250
200
150
available
100
50
0
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Assessment units
are storage units to
When is the Specialist Capacity available? hold the patients until
the specialist capacity
X junior is available the
staff
+ following day
Minimal Y Minimal
capacity specialist capacity
consultants?
00.00 06.00 12.00 18.00 23.59
70. Assessment Process at April 2009
Up to 24
4 hours. Up to 12 hours overnight hours post
arrival at hospital
Arrive History & Requests Perform tests Perform tests
At Triage Nursing examination Test &
Obs‟ & imaging & imaging
A&E & initial imaging
treatment Senior
review
Transfer to Assessment Unit
Nursing History & Senior Review
Obs examination Plan definitive
treatment
?
A&E Assessment Unit
= value
71. What do we need to do instead?
Pull patients forward into the working day:
450
Time of Arrival into A&E Time of Departure out of A&E to Main Hospital
•Stop making them wait 3:59 minutes…..
400 •Stop duplication
350
300
250
200
150
100
50
0
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
The specialty capacity needs to be available: Right decisions
On time
08:00 21:00
Every time
Specialists available In full
Seeing patients on wards
Minimal Discharging patients
capacity Admitting patients
00.00 06.00 12.00 18.00 23.59
72. „Future‟ Assessment Process
(Now current as at April 2012)
2 hours
Transfer to
Appropriate
History & Senior specialist
Arrive Plan Requests specialist area
Nursing examination Perform tests Review
At for Test & including home
Obs‟ & initial & imaging Plan definitive
A&E diagnosis imaging with PT/OT /SS
treatment treatment
home assessment
at home
1 hour
Safe ambulatory care process now possible
74. All admissions from A&E by hour
Mondays May to Oct 08
8
7
Reduce daily
6 variation in
discharges
5
Max
Admission
Min
4 Avg
Av + 1 SD
Av +2 SD
3
2
1
0
00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Hour of arrival
What is the rate of production required?
76. Improving Flow (front end)
• Pooled junior docs
– A&E, MAU and specialty on call
– Staggered start times on A&E/MAU
= Increased availability from 08:00 to 10:00
• MAU consultants continuous flow
• Speciality take every day: admissions
• Heartbeat system for tracking patients
• Wards
– Consultant ward round every day: discharges
77. Functional departments
DH, SHA, Monitor, Health Commission etc.
Board Board
GP GP Flow
Emergency
Planned care
Clinical subspecialties
Medicine
Intermediate care
Surgery
Community hospitals
Paediatrics
A&E Long term care Functional
Ambulance Departments
Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport
HR IT Finance Estates Supplies Support
functions
78. Do this hour‟s work this hour:
• Emergency Blood turnaround:
– Bottleneck for emergency samples = centrifuges
Change:
• Now a centrifuge starts every 3 minutes whether full or not
• IP blood monitoring on wards
– Bottleneck: Phlebotomists & transport to lab
Change:
• Porters running between phleb‟s and lab
• Steady flow of samples into lab
• all results back by 10:30 a.m. for ward rounds
79. 1 year later
• Warwick
• Focus on:
– A&E,
– Assessment units and wards
– Diagnostics
– Ward rounds
– TTOs
80. Foundation Close
Status Community Dec 2010: flow improvements start
deferred Hsp Sept 09
Increased %
16 to 64 years
Flow doesn‟t
recover from
Sept 2009
bed + staff
closures
Infection control Palliative
Care
excluded Reduction in death rate Nobody
addressed
the CHC
admin delays
Acquire
causing the
Community long LOS
services
Open new wards Organisation
Recruit
Agenda for change
change
disrupted the
Admin flow
even more
Comments?
81. 1 Year later
• Sheffield
Geriatric and stroke medicine
– Focus on reducing the admin constraints (policies)
– Check List and CHC assessment process
• 42 page document
• 18 man hours of work
• Min time (LOS) = 30 days+
– Home assessment at home on day of discharge
• Referral to Social Services by physio to social services
• SS package in place within 48 hours (Upper process limit)
– Home of choice:
• out to residential home, CHC afterwards
83. Lessons for executive support services
DH, SHA, Monitor, Health Commission etc..
Board Board
Emergency GP GP Flow
Planned care
Clinical subspecialties
Medicine
Surgery Intermediate care
Paediatrics Community hospitals
A&E Long term care Functional
Ambulance
Departments
Clinics Radiology Pathology Theatres Wards Pharmacy Therapies Transport
HR IT Finance Estates Supplies Support
functions
84. Lessons for executive support services
• HR:
– Systems thinking and improvement science for A4C 8 & above
– Match staff capacity to patient demand: 7/7, 365
– Heads of functions = responsibility for end-to-end process
Focus is on Flow,
WIP incurred accountable to the Dpt. concerned.
• IT
– Information in real time
– Time series data
• Estates:
– Reduce transport and motion
– Co-location of process resources
• Supplies
– Just-in-time
86. Pareto analysis of the pay costs in one Trust
for one month by employee.
50% of cost
Role of senior managers is to
improve process flow
20% of staff through the most expensive
value adding staff =clinicians
87. Change the Finance Paradigm
Economies of Scale Economies of Flow
Capacity Nu,ber of Patients
Patients/hr treated
successfully
Land lives „saved‟
Demand
Patients /hr Activity
£5 £2 x PbR
£1
/hr /hr £1 income
Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6 /hr £2
£1 /hr
/hr /hr
Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6
Department Cost
Activity = waste
= unit cost constraint
So focus is on improving value delivered and income
Drives Dpt manager to This depends on moving resources to support the constraint
do more activity at less cost The constraint should be the most expensive resource
Acquires „new business‟ in the process = in Dpt 2.
But what happens to flow? How can we optimise productivity through the most
expensive resource?
90. Get Everyone on Board
Patient‟s experience of waste
Discussion
History Full Endoscopy Discharge
Nil by Rest & Check Cross with cardiac
Examination blood & Transfuse With Plan
mouth dehydrate FBC match centre
Assessment Count Breath test 8 hours And Rx
4 hours for 20 5 minutes 40 mins Re stent
30 minutes 5 minutes 30 minutes 15 minutes
hours 15 minutes
Value adding 34 hours = 18% of time value adding
Non Value adding 8 days x 24 hours
82% of time and resource wasted
Poor quality experience and outcome
From a Poor Quality System
91. The Doctors can lead the change…..
• Very complex system:
– Like a human body!
• Understand
– Anatomy
– Physiology (flows)
– Plot the dots: BP, temp, pulse, resp‟s ….
– Diagnosis
– Treatment (releave the constraints)
– Look for changes in the pattern of variation (SPC)
92. Get the Managers on Board
• Top Down Command and Control is impossible:
– Not possible for one person to understand whole end-
to-end process or System.
• Facilitate Big Room Meetings
– Get the everyone in a room
– Listening to each other
– Conversations based on facts:
– Study, Adjust, Plan, Do,
– Monthly and Weekly reviews
94. Summary
• Quality is a System property
• Track patient flow (WIP), death rate and cost over time.
– Increasing cost doesn‟t always improve flow
– Reducing cost can have grave consequences
• Improve processes to reduce delays and inventory (WIP)
– Match staff capacity to patient demand
– Do this hour‟s work this hour
• Shift from:
– Unit Costing: Dpt cost/activity
– to Flow Accounting: throughput at constraint/total process cost
– The constraints are policies or availability of staff, not beds.
95. What have we learned ?
• Nuggets
• Niggles
• Nice-if
• NoNos
Notes de l'éditeur
Using our data to understand our flow, we were able to highlight the impact of our current system on the timeliness of patient care delivery.
