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

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

4. Physician 1 Radiologist Surgeon 1 Number of specialists 2 3 4 2 3 4 5 urgent x x x x x x x x x soon x x x x x x x x x routine x x x x x x x x x x x x x x x urgent x x x x x x soon x x x x x x routine urgent soon x x x x x x x x x routine x x x x x x x x x x x x x x x x x x x The size of the carve out Flexi-sig Colonoscopy OGD ERCP Number of appointment types 73 queues

5. Server Server Server Server Server Server Server Server Queue type A Queue 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 eliminateunnecessary 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. 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?

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

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

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

14. 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

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

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

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

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

19. Monitor progress

20. Condition 1 Condition 2 Condition 3 Condition 4 Condition 5 Condition 6 Consultant EE Consultant CC Consultant DD Consultant AA Consultant BB Consultant FF Matrix Allocation: Step 1Draw a matrix

21. Ensure all conditions have at least one consultant x x Condition 1 x x x Condition 2 x x Condition 3 x x Condition 4 x x x Condition 5 x x x x x x Condition 6 Consultant BB Consultant CC Consultant DD Consultant AA Consultant EE Consultant FF Step 2Fill in the matrix

22. x x Condition 1 x x x Condition 2 x x Condition 3 ccg 1 x x ccg 2 Condition 4 x x x Condition 5 x x x x x x Condition 6 Consultant CC Consultant DD Consultant BB Consultant EE Consultant AA Consultant FF Step 3Establish clinical care groups

23. Clinical care group 4 Consultant BB Consultant CC Consultant DD Consultant AA Consultant EE Consultant FF Step 3Allocate patients Patient with condition 4

24. 40 35 30 25 20 15 10 5 0 70 Ophthalmology Outpatient Waiting List vs List for patients booked in turn 60 50 Actual Outpatient Waiting List Booked in Turn 40 Number 30 20 10 0 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 8 6 4 2 0 Wait (weeks)

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

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

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

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

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

30. Prepare patient Write notes Prepare bowel Scope Recover balance Patient Nurse Endoscopist An example of scheduling the bottleneck Flexi-sigmoidoscopy 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

31. 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! endoscopist can’t start till late Line up the templates Wasted time Only 4 patients done What is the constraint? (defining capacity) What is the bottleneck? (current limit on activity)

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

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

34. 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

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

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