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Diagnostics and Constraints Theory

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Title: Diagnostics and Constraints Theory


1
Diagnostics and Constraints Theory
  • Marcus Kennedy
  • Clinical Lead
  • Patient Flow Collaborative
  • 4th May

2
From project to habit
  • Themes of today
  • Reinforcing what we have learnt
  • Showcasing improvements
  • Making these effective methods part of every day
    business

3
A story
  • Hospital x identified an elective surgical
    throughput value stream
  • Access problems
  • Waiting list blow outs
  • Admission systems chaotic
  • Theatre bookings whimsical
  • Not meeting targets
  • Losing bonus dollars
  • Losing surgeons

4

HELP !!!

5
PFC
6
Why Multidimensional?
  • Because this was the NHS way?
  • Because Jenny Bartlett said so?
  • Because this way we could see and appreciate
    whole systems from all perspectives
  • Organisational
  • Patient
  • Workers
  • To avoid tunnel vision and myths

7
Theory of Constraints
  • like a chain with its weakest link, in any
    complex system at any point in time, there is
    most often only one aspect of that system that is
    limiting its ability to achieve more of its goal.
    For that system to attain any significant
    improvement, that constraint must be identified
    and the whole system must be managed with it in
    mind

8
The Five Focusing Steps of the Theory of
Constraints (TOC)
  • Identify the system constraint.
  • Although a system will have many processes, few
    will represent a constraint to the overall
    system. The more complex the system, the more
    likely it is that there will be a single, overall
    bottleneck
  • Get the most out of the constraint
  • since it determines system throughput. The entire
    value of the system is represented by what flows
    through the bottleneck. For instance, you would
    want to keep the bottleneck working all the time,
    since your whole system is idle if the bottleneck
    is idle
  • Support the constraint
  • by making it only do work that cannot be done
    elsewhere
  • Elevate it
  • within the system so that all other parts work to
    help it
  • Return to step 1
  • because a different process may have become the
    constraint

9
Constraint Theory
10
Hospital x Identified Constraints
  • Discharge incoordination due to registrar OR
    commitments
  • Booking system organisation
  • Availability of fluoroscopy in OR

11
Lean approach
  • Understand Customers and what they value
  • Define the internal value stream
  • Eliminate waste, make information products
    flow, pulled by customer needs
  • Extend the definition of value outside your own
    company
  • Continually aim for perfection

Terry Young, Sally Brailsford, Con Connell, Ruth
Davies, Paul Harper and Jonathan H Klein, Using
industrial processes to improve patient care BMJ
2004328162-164
12
Understanding the wastes of lean
  • Overproduction
  • Producing too much too soon, resulting in poor
    flow of information or the deliverable and excess
  • Defects
  • Frequent errors in paperwork, data and
    information, product quality problems, or poor
    delivery performance
  • Unnecessary information or inventory
  • Excessive storage and delay of information or
    products, resulting in excessive cost and poor
    customer service
  • Inappropriate processing
  • Going about work processes with the wrong set of
    tools, procedures of systems, often when a
    simpler approach would have been more effective
  • Excessive transportation
  • Excessive movement of people, information or
    material, resulting in poor flow and long lead
    times
  • Waiting
  • Long periods of inactivity for people,
    information or material, resulting in poor flow
    and long lead times
  • Unnecessary motion
  • Poor workplace organization, resulting in poor
    ergonomics, eg excessive bending or stretching
    and frequently lost items

13
Im a textbook hero !
14
Solution to key constraint
  • Event driven discharge
  • Patients went home .6 days earlier
  • Capacity improved
  • Therefore inspired by sweet success the team
    moved on and tackled the second constraint
  • Booking system organisation

15
Booking system improvements
  • Streamlined
  • Removed duplication
  • Single assessments
  • Removed paperwork
  • Automated messaging and contacts / reminders

16
Impact -2730 C
17
Why is it so?
18
Shifting Constraints
  • Now that event driven discharge allowed shorter
    LOS
  • Allied health services required on the day of
    discharge were unable to meet demands

19
Systems are dynamic beasts
1
3
2
Initial constraint analysis
20
Complex Systems
  • We deal with complex, multiply intersecting and
    interdependent systems
  • Not linear independent production lines

21
Chaos Theory
  • The relationships within these chaotic systems
    are not always initially clear
  • Beware of assumptions (aka myths
    preconceptions) these are the inherent flaws of
    many of our less effective previous strategies
  • Continuous measurement and analysis
  • Continuous Whole system orientation

22
Repeat analysis
  • Repeat diagnostics / constraint analysis
  • Tailor
  • Refine
  • Embed methodology
  • Actively revisit Lean Methodology interventions
  • Targeted at constraints
  • Beware fanatical / untargeted application in a
    complex / chaotic system
  • Intervention theme not a new organisational
    religion

23
Project to System
  • Do something or nothing will happen
  • Current bed management PFC way to go
  • Executive links
  • Redefine TOR
  • Actively build in Constraint Theory Lean
    Thinking
  • Celebrate achievements

24
Data
  • Selected (refined) data presentation of previous
    month and week
  • Forecast data presentation for next week (based
    on historical/previous yr data and known current
    activity threats)

25
Strategy
  • Current Flow Improvement Strategies (presented in
    action table)
  • achievements since last meeting
  • challenges encountered in progressing plan
  • known threats for next week
  • plans for next week
  • actions points

26
Policy and Procedure
  • review of flow policy and process breaches over
    the last week
  • actions defined

27
Retain Methodological Context
  • Review of Constraint Table (Fortnightly)
  • Lists Organisational Value Streams, with
    identified key constraints per stream and action
    priorities.
  • Identifies next actions re improvement and allows
    forward planning of implementations.
  • Drives knowledge of constraint theory and lean
    thinking methodologies

28
Anticipation
  • Review of Threats (Monthly)
  • The month ahead is assessed with regard to
    perceived threats to patient flow eg public
    holidays, staff changeovers, public events,
    conferences and other leave, known infrastructure
    changes, shutdowns or decrease in performance.

29
New Hospital Access Targets
  • Tens of Million
  • Matters to the base budget
  • Achievement
  • Go harder and faster
  • Do something different
  • Those that have already implemented change are
    advantaged

30
  • 12 months down the track
  • Are expectations (culture) of flow different?
  • Are systems changing to achieve this?
  • Have we achieved all we needed to?
  • Have we got the right tools?
  • Have we learnt to use them optimally?
  • Will we get there?

31
  • Questions

?
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