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A Practical Approach To Improving patient flow using The Theory of Constraints

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

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A Practical Approach To Improving patient flow using The Theory of Constraints

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  1. 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 - Mapthe System) Step 1 - Identifythe Constraint Step 2 -Get the mostout of the constraint Step 3 - Supportthe systems constraint Step 4 - Elevatethe systems constraint Step 5 - Go backto 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 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. Discharge beds

  23. 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.

  24. 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.

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