Theory of Constraints

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Theory of Constraints
CARDIFF AND VALE NHS TRUSTYMDDIRIEDOLAETH GIG
CAERDYDD AR FRO

• Joy Whitlock
• Service Improvement Manager

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Outline for session

• TOC basic principles
• What does your organisation look like?
• TOC project management principles (Critical
  Chain)
• Cardiff Vale NHS Trust experience
• Where could you use the methodology?
• Anything else?

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Can you simultaneously increase the number of
patients treated

• And maintain quality of patient care?
• Without making staff work harder?
• Without increasing resources?

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Current reality dilemmas
Recognise clinicians as a key/powerful resource
and support them in following their NHS, private
and research agenda
Plan prepare change practices
Implement radical change where no real
breakthrough has ever been achieved
AND
Increase control and reduce risk taking to assure
compliance
Force clinicians to align with Trust objectives
Deliver against todays targets
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In order to achieve a substantial improvement in
our ability to manage the patients journey we
must ask
What to change?
What to change to?
How to cause the change?
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The Theory of Constraints, developed by Dr Eli
Goldratt and described in his novels, focuses on
achieving breakthroughs in performance in large
complex environments, dominated by high
uncertainty.
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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.

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ToC Why?

• 80s industry
• Whole systems
• Continuous process
• Oxfordshire challenge - 1st health community

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Theory of Constraints

• Every Chain has a weakest link the strength of
  the chain as a whole is determined by the weakest
  link

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THE THEORY OF CONSTRAINTS
THE FIVE FOCUSING STEPS
Step 1 Identify the systems constraint
Step 2 Decide how to exploit the systems
constraint
Step 3 Subordinate everything else to the above
decision
Step 4 Elevate the systems constraint
Step 5 If in the previous steps a constraint has
been broken, go back to step 1.
Warning Dont allow inertia to
cause a system constraint
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TOC Applied

• Identify constraint data collection, process
  map, other information
• Exploit the system
• Provide a buffer to protect it
• Ensure it only does what it has to
• Control flow critical chain project
  management/process templates/reduce variation/
  reduce batching
• Redesign using existing resources
• Subordinate everything else
• E.g. theatre porter

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Types What types of constraint are
there?Constraint

• Physical constraint a capacity limited resource
• Thinking constraint Weve always done it like
  that
• Policy constraint an organisational policy
  whether written or believed

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Your organisation

• What does it look like?
• Where are your problems?
• What evidence do you have?
• What are your solutions?
• How do you know what to change what to change
  to?

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INHERENT SIMPLICITY
This system seems quite complex.
How much does it resemble the system you work in?
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The common way to deal with complex system is to
dissect it into sub-systems - trying to mange
each function in isolation.
What are the drawbacks?
Miss-synchronization, Silo mentality, Local
optima conflicts to name a few.
LOCAL OPTIMA DO NOT ADD UP TO GLOBAL OPTIMUM
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INHERENT SIMPLICITY
Very Few Factors Govern The Performance Of The
System!
Theory Of Constraints recognizes this as the
inherent simplicity of the system.
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Theory of Constraints (TOC) Critical Chain
Project Management Principles
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Uncertainty and Safety
Common Practice The way to ensure that the
project will finish on time is to try to make
every task finish on-time.
Reality of ProjectHigh uncertainty, therefore,
tasks time cannot be determined - they can only
be estimated.
Common Practice The Common practice turns
estimations into commitments
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Estimating task times

• Are you ever interrupted as you do your work?
• Do things sometimes turn out to take a bit longer
  than anticipated?
• How often do you find yourself working hard to
  make an impending deadline?
• How do you estimate realistic task times?

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Estimating task times

• If you had to deliver on time, towards which end
  of the distribution would you rather estimate
  your task time?

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Estimating task times

• Realistic task time estimates often correspond
  to a due date on the tail of the distribution

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A contradiction?

• If everyone is adding safety into their task
  time estimates, why do so many projects finish
  late, over budget and cut specs?
• Safety time is wasted through
• Student Syndrome
• Parkinsons Law
• Bad Multi-Tasking

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The student syndrome
Work Rate
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Parkinsons Law

• Work expands to fill the time allotted
• Parkinson
• Gold-plating
• 3 Minute Egg
• Delays in reporting early finishes

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Conclusions

• The student syndrome means tasks are started
  close to their deadlines
• The safety time factored in the task time has
  been used elsewhere
• The chances of finishing early diminish
• The chances of finishing late increase

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How do we function?

• Complex organisations
• Often poor critical chain or other project
  management principles to manage work flow
• Poor for emergency admissions
• Good for patients following care pathways

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TOC in Cardiff Vale

• Emergency Department Discharge Planning
• Apply 5 focusing steps of TOC
• Critical chain project management to each patient
• Dynamic buffer management

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WHY ARE WE TALKING ABOUT PROJECT MANAGEMENT?
Lets Check

• Each patient has a unique set of project needs
• Each project shares multiple finite resources
• There is varying degree of uncertainty
• There is a need to meet timescales, budget and
  scope for each patient/project
• If we agree with this we are talking about a
  Multi Project Environment

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CRITERIA FOR THE SOLUTION

• Simple and very practical
• Minimal administration
• Easy to use
• Implemented with minimal disruption and cost
• Manage uncertainty
• Ability to identified problems with projects
  early enough
• Ability to focus in on the key constraints of
  the whole project portfolio
• Relevant information available to all involved
  in the Multi Project environment
• Priorities demands on resource managers (not
  based on who shouts the loudest)

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The Goal

• The Goal of every admission is to discharge to
  another environment
• The Aim of admission is to provide treatment to
  achieve the goal
• If the goal and the aim are not linked then
  delays occur

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DYNAMIC BUFFER MANAGEMENT

• Split the patients journey into 3 zones green,
  amber, red.
• Actively manage patients in the amber buffer
  zone. Patients in the Red buffer zone to be
  expedited (advance) through their journey to
  prevent breaching into Black buffer zone

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MANAGING THE PROJECT BUFFER MANAGEMENT

• Buffer Management - by tracking the buffer zones,
  the project manager can decide upon
• What corrective action is required
• When the corrective action needs to be
  implemented
• Who is involved in the corrective action

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Jonah Databases

• Designed by clinical staff to support discharge
  planning
• Uses a clear end point for the patients journey
  (4 hour target or PDD)
• Based upon Goldratts Critical Chain Project
  planning
• Takes into account patients with complex and
  non-complex discharge needs
• Records reasons for delay (Step 1 identifies
  constraint)

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Jonah Discharge Process

• Based upon 4 hour journey or PDD Predicted date
  of Discharge.
• System is predictive - traffic lights that allow
  corrective action to take place early if plan
  looks like running late
• Uses principles of project management.
• High visibility and ownership by core users

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Buffer meetings

• Weekly multidisciplinary ward meeting
• Top 5 delayed patients or patients who are
  predicatively delayed project plan/escalate
• Monthly DMs meeting to address system constraints
• Monthly heatlh community executive meeting
  commissioning policy issues top patients to
  test new ideas/ways of working
• ED look at system delays

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Escalation

• Escalation process for
• named patients who are delayed
• internal process delays
• whole health social care issues

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Summary Rules

• Any system can only work as fast as its slowest
  necessary component (make sure it keeps working
  provide a buffer)
• Within any delivery system bottlenecks can be
  identified which if they are eliminated will
  result in a step change in performance

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System Flow Results

• All DTOCs reduced highlighted national
  variation in reporting
• Mental Health DTOCs down for the first time since
  TOC has been implemented (94 78)
• Empty beds on MH assessment wards flow
  improving towards a pull system
• ED SaPHTE scores improved
• 95 target significant statistical improvement
• Average LOS across the Trust 8 of last 9
  observations have been lower than the mean

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Improving the Discharge Process / Managing
Emergency Admissions
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Where could you apply TOC?
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Helen Bevan Four rules of change

• Duration we dont need to execute change
  quickly
• Support from the top
• Senior management-led review process
• 2. Performance integrity right mix of team
  members to deliver change
• 3. Commitment visible backing from most
  influential senior leaders enthusiastic support
  from staff
• 4. Effort
• Space for change
• Ref HSJ 3rd Nov. 2005

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Thank you

• Joy.whitlock_at_cardiffandvale.wales.nhs.uk
• 02920 74 5099