Creating patient flow

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Creating patient flow

Richard Hamilton, Brian Dolan and Michael Ardagh

Chapter Contents

This book is dedicated to the improvement of individuals’ clinical and professional skills in emergency care. For some time now all the authors have been studying and working in wide-scale health system reforms and this work has exposed us to a wealth of knowledge that has enabled us to reconsider how we best serve communities of health need (Dolan & Hawes 2009, Ardagh et al. 2011). We realize now that in healthcare we have a responsibility as health practitioners beyond the patient in front of us right now; we have a responsibility to the patient in the waiting room, arriving in the ambulance, and to the patient who may not know they will shortly be on their way to the Emergency Department (ED). In other words, ensuring we are ready to handle the next patient that comes through the door in the same way we manage the patient in front of us right now, no matter how busy it gets.

This chapter introduces the key concepts of patient flow and how this impacts on both the immediate work environment and the journey of the patient seeking care. It introduces some of the techniques used in manufacturing and service industries and its application to health systems. This is by no means a comprehensive study of methods and tools, but an introduction to some key concepts and should act as a guide in the journey to making not just the patient but the health system better.

Health system environments

Health systems have not evolved significantly in the way they are organized in the last 100 years. New technology, bigger, brighter and more welcoming buildings and new clinical techniques mask what essentially is an industry that has kept its Victorian design into a new millennium. Just like craftsman-type industries prior to the 20^th century industrial revolution in manufacturing techniques, health is a collection of inter-related cottage industries (Swensen et al. 2010). Every clinical service can be compared to a craft-based business of old, where highly specialized individuals within a particular clinical specialty deliver specialist knowledge and techniques. A hospital is often like a large mall full of specialist businesses to which a patient is sent for expert assessment. As a result the patient gets passed from service to service, from cottage industry to cottage industry, during the course of their care and treatment.

The organization and leadership of hospital resources further exposes this sense of passing the patient from one process area to another. Figure 42.1 highlights how a hospital setting is a matrix of services attempting to get patient outcomes via a series of functional business areas that are vertical silos. Traditionally, the management model of hospital systems has focused on managing the functional business units, or the vertical slices of the patient journey, often as discrete businesses. Each functional business unit is charged with being as efficient as possible with the resources they are given, where the resources are usually monetary based. In this way each independent business is seeking to maximize the use of its resources to achieve either more revenue, reduce costs or higher utilization of resources. These functional business units serve many different clinical specialities whose needs can be very different and competing; therefore, by default, they create their own rules and business practices that may not align with the other functional business units.

Figure 42.1 Matrix of healthcare.

In the clinical service context (the horizontal slice), they are looking to move patients through the functional areas at a regular rate. The clinical services must meet the patient demand on their service and navigate the patient through each of the functional business units to create the right patient outcome.

This process can be very frustrating and disempowering for the clinical teams. The response can be to shrug one’s shoulders and say ‘that’s how it’s done around here’. Again each clinical service creates its own way of responding to the pressures on its service. So, while surgeons may take a long time to appear in the ED and make prompt decisions about patient admissions, physicians may be prompt in arrival but take an apparently protracted time to make a decision to admit. From a patient perspective there is an equally large variation in response and service in this type of environment. No two clinical events will be the same from a patient perspective, even when they attend regularly with the same presenting symptoms.

This traditional approach to hospital and specialist care creates a focus on episodic care rather than holistic care of the patient. How do we view this system with a fresh perspective?

Patient time

Health systems operate as complex supply chains where the goal is to achieve timely and appropriate outcomes for the population’s needs. Where manufacturing systems are moving inventory and parts around the world to wholesalers and assembly plants; health systems are managing time – patients’ time. Where Toyota is concerned about limiting its inventory to the next few hours of production as a way to reduce the time from paying suppliers to being paid by product buyers (Womack & Jones 1996), the health system has a focus on reducing the time a patient spends in the health system from the start of a health issue to the time the issue is resolved. In many respects, patient time is the health system equivalent of inventory.

Why is patient time so important?

Hospital systems can be likened to large warehouses of a supply chain where instead of storing parts and products like a manufacturing business, we are storing patients. Patients are stored in waiting rooms, cubicles, clinic rooms, beds, trollies, wards and discharge lounges; indeed, we even store them in their own home; with the home being the default waiting place for most patients on ‘waiting’ lists. A lot of the patient’s time in the health system is spent waiting; waiting for appointments, assessment, diagnostics, the next decision, clinical intervention, admission/discharge, etc. Some of the patient’s time in a health system is necessary such as waiting for a therapeutic response to treatment, but much of the patient’s time is wasted. Practitioners see these waits and delays, but become inured to them as we are always busy and having to prioritize our time where it can best be spent.

As a result, the health system has been inadvertently designed around staff needs, where staff are considered a precious and scarce resource that needs to be optimized. In some health systems staff are seen as a high cost so resource time must be optimized.

But what about the patient’s time, does that not have value as well? Imagine you are 81 years old and have just been advised that you need a hip replacement but cannot be seen for another six months, how would you feel knowing, on average, you probably only have another 24 months of life left. Time becomes very precious and the quality of time even more so. You do not want to be spending the latter years of your life in a hospital or at home on a waiting list, waiting for something to happen to you.

In the movie The Bucket List, Jack Nicolson and Morgan Freeman play two men, brought together in hospital, living on borrowed time, who are determined to live the last days as if they were the first. They remind the viewer of how precious time is, especially in the twilight years of life. So in a patient-focused health system, patient time and quality of life are guiding principles to system design. There are other reasons why patient time is such an important metric to the efficiency of any health system.

How Lean Thinking principles value time

Over 40 years, Toyota Motor Company has developed the Toyota Production System using techniques that are known more widely as Lean Thinking (Womack & Jones 1996, Stone 2012). Lean Thinking is a culture focused on delivering the most value with the least waste, for the end consumer (Liker & Convis 2011, Kaplan 2012). It has been designed to support complex supply chains, focusing on:

• ‘just-in-time’ (JIT) delivery of products thus minimizing storage space

• error-proofing processes, thereby minimizing waste and delays due to poor parts

• continuously eliminating excessive product movement/handling to create the fewest steps, therefore lessening the chance of errors (Westwood et al. 2007).

Staff in a Lean Thinking environment understand the importance of time and quality and the role they play in the supply chain. The goals of Lean Thinking are simple but intuitive and are based on a set of values where time is considered the most precious. The time it takes from paying suppliers and being paid by the consumer for the end product; or the time a patient spends in the health system.

The focus behind this philosophy is to keep inventory levels low, as the more parts sitting around in the supply chain the greater the cost of production and the longer the time it will take for the part to add value to an end product that the consumer will buy. The larger the number of parts in the system the bigger the warehouses we need to store them, therefore the more people needed to manage the warehouses and therefore the more money tied up earning no value for the shareholder; the risk of parts being scrapped goes up as well. This is the key driver of Lean Thinking; reducing the materials, effort and lead time required to produce a product that the customer is willing to pay for.

In patient terms, the longer patients wait, the more staff effort is involved, bigger waiting rooms are required, poorer quality of care can result. There is a direct correlation between waiting times in EDs and increased morbidity and mortality (Ardagh & Richardson 2004, Richardson 2006, Sprivulis et al. 2006, Richardson & Mountain 2009, Johnson et al. 2012, Mahler et al. 2012). Industry has much more to teach healthcare than we sometimes imagine, as it has addressed metaphorically similar issues many years ago. To achieve this focus Toyota recognized the contribution of staff, and in particular they recognized and valued frontline staff as long-term partners that learn, adapt and empower improvements. Managers and leaders in Toyota are driven to value frontline staff and their time; with particular emphasis on removing barriers to staff creating more value. Having staff spend time on producing a part that is not needed now, it may be needed but not now, is seen as disrespectful of the staff’s time; the work has added no value (Liker & Franz 2011). Having staff skills and capabilities under-utilized is also considered disrespectful of staff time, i.e., the time they have invested in developing these skills.

Lean Thinking during the first decade of the new millennium has been adopted widely by health systems and is increasingly recognized for its potential to transform individual business processes (Baker & Taylor 2009, Millard 2011, Stone 2012). The true value and opportunity is where the tools of Lean Thinking are applied across the health system, across the patient’s journey, where the patient is a substitute for inventory in a manufacturing environment, which must be moved through the health system in a timely manner. It is important to stress that in viewing the patient as metaphorical inventory is not about being disrespectful, rather the opposite, it is underlining that principles that apply in industry can readily be applied in healthcare. A true Lean Manufacturing culture seeks to have inventory valued in the same way we value people, with respect.

The concept of patient time being important in health systems and the reasons why it is so important can be hard to understand as it can be counter-intuitive to logic and professional training. The process for managing patients has its roots in Napoleonic warfare and is now pervasive in all clinical practice. The use of triaging and prioritization scores is viewed as a normal and necessary practice for determining who needs help now and who can wait, and who will never be seen (Allen & Jesus 2012). In war, where demand can rapidly outstrip supply of clinical resources, the use of battlefield triage makes sense; but why does this methodology continue in everyday practice? The underlying assumption of triage is there are not enough resources to treat everyone that seeks our help (see Chapter 35).

However, is this really true for normal population clinical needs? Most health systems are adept at treating the demand on the system; it’s just a matter of when they are treated. With the exception of emergency care where critical care demand may impact on resources, most of healthcare demand is stable and predictable. The biggest variable is created by us, the health professionals. By prioritizing demand (triaging), patients are placed into queues based on urgency of need. Every time someone with a higher need enters the system, someone of a lower need is asked to wait longer. This reprioritization may not be transparent to the majority of patients and staff as it happens on waiting lists, where the patient is waiting at home; but what about the patient that comes to the ED who may be categorized as triage 3 and ultimately is assessed as needing surgery? Every time a patient with a higher need comes into the system this patient will be asked to wait longer. In extreme examples, these patients may have been ‘nil by mouth’ for three to four days, sitting in a hospital bed waiting for access to a treatment room or operating theatre. The patient’s condition may have deteriorated and they pick up a hospital-borne infection. This patient initially needed a fifteen-minute surgical procedure, and would have gone home the same day. Instead they spent a week in hospital using up resources that could have been applied in other ways, as well as suffering needless pain, harm and distress. In patients with fractured neck of femur, the correlation between non-medical delays in surgery and increased morbidity and mortality is now well established (Bottle & Aylin 2006, Kalson et al. 2009).

This all too common story highlights how health professionals prioritize patients based on immediate medical need, with the underlying assumption being ‘we do not have enough resources to treat everyone right now’, so people have to wait. Health systems that are focused on valuing patient time understand this dynamic, and like Toyota realize the potential to release resources from tasks that add no value, such as storing patients that are waiting – waiting on waitlists, in waiting rooms, in ward beds, etc. The mindset of a Lean Thinking health system focuses on the way resources are used, before considering if there are enough resources.

EDs that use ‘streaming’, for example, split their capacity and resources into two separate patient streams, minors and majors, are focused on applying a key principle of Lean Thinking, First In First Out (FIFO). By streaming patients based on need, it is possible to prioritize patients based on time of arrival rather than just need. In this way patients with relatively minor conditions are processed faster (high turnover) with a focus on creating flow. This is also the theoretical basis of See and Treat (NHS Modernisation Agency 2004, King et al. 2006, Hoskins 2010).

Such an approach requires careful consideration of clinical capacity; understanding how much work is required in each stream, how frequent the work comes in, and having tools to predict future demand and potential changes in demand. Having event plans and buffer resources for those true emergency events that only occur occasionally and are outside normal variation of demand is another key design consideration. This chapter does not address the topic of capacity design in detail.

Creating goals of patient flow

Manufacturing companies create value for their shareholders by reducing the time inventory is in the supply chain; but health systems don’t create money by reducing patient time. Or do they?

Average length of stay in hospitals is an important measure of ward capacity performance as the higher the number of days, or indeed hours, a patient spends in the system the more direct resources they consume, such as beds/chairs, rooms, food, laundry, etc. The more time people spend in hospital, the bigger the hospital space and staffing resources required to store and manage patients and their visitors; therefore, the more patient time in the system, the more resources we need to have, either directly managing patient treatment or indirectly managing the patient journey, such as waitlist, etc. The other risk for patients is that the more time they spend in hospital than is essential, the greater their risk of picking up healthcare-acquired infections (HCAI), which not only adds to their length of stay, but more importantly, adds needless harm and suffering. In Europe, HCAIs cause 16 million extra bed days and 37 000 attributable deaths and contribute to an additional 110 000 deaths every year (World Health Organization 2010).

For this and other reasons, access goals are expressed in patient time, e.g., no patient will spend longer than four hours in the ED, no patient will wait longer then 24 hours for an emergency operating theatre; no patient will wait longer than 2 hours for a radiology report.

By defining goals as stated outcomes, we intuitively seek information about why these goals are not achieved. Reasons patients breach the goal are analysed and we seek to modify the conditions that enabled the failure to occur. We seek out information and learning that will help us understand the cause and effect, and strive to find alternative methods that ultimately make it better for all patients.

Does your environment have clear goals? Are these goals based on patient time or quality of outcome; and do they encourage continuous improvement? Without these clear goals how do we know if we are making a difference. Beyond gut feeling, how do we know if we have had a good shift today or a difficult one? While EDs in most countries now have goals or more commonly ‘targets’, usually four or six hours from ED arrival to discharge or admission/transfer, staff frequently feel they are imposed. They remain an ED and not an organizational health system target, and in reality it’s the nurses who make it happen. Even when the target is reached, too often it is with more a sense of relief than achievement. This is not what Lean Thinking and patient flow is about, which is to create sustainable and in many ways self-sustaining systems that continue to focus on improvement not plateauing and ultimately reversing earlier success. Lean Thinking is not about the tools, it’s about the thinking that underpins it, and a relentless focus on eliminating everything that does not add value to the patient’s experience and safety of care.

Identifying waste in the health system

As indicated above, waste is a significant problem in healthcare and indeed all service and manufacturing industries. As little as 10 % of all activities provide value, which may be defined as adding ‘value’ to the customer, be they a patient or member of staff (Baker & Taylor 2009). Box 42.1 defines and provides numerous examples of waste using the mnemonic TIMWOODS and underlines that, perhaps counter intuitively, the greatest challenge in healthcare is not necessarily the lack of resources, but the enormous levels of waste that exist.

Box 42.1 Identifying waste

Waste may be defined as anything other than the minimum amount of equipment, people, materials, space and worker’s time which are essential to add value to the product or service. Put in a different way, if it does not add value then it is waste. Waste is a symptom, and not a cause of a problem.

Waste may be described using the mnemonic TIM WOODS standing for:

Staff under-utilization

Transportation

Moving patients or products that are not required to perform the process:

• Transporting patients to surgery prematurely

• Placing a ED trolley in the hall and constantly having to move it

• Staff looking for patients’ notes

• Excessive movement of patients

• People not returning equipment to the correct place

Inventory

Too much work in progress (WIP), work piles, excessive supplies, signature requirements, information:

• Extra or outdated manuals, newsletters or magazines

• Excessive office supplies

• Obsolete supplies, charts, files, and equipment

• Duplicate medications

• Stockpiling supplies of any kind

• Waiting lists

Motion

Unnecessary movement of people, paper, and/or electronic exchanges (see Figure 42.2 spaghetti diagram for example of motion waste):

Figure 42.2 Spaghetti diagram of drug round (15 minutes).

• Searching for paperwork, case notes, medication charts, and/or medications

• Searching for patients

• Searching for poorly located supplies, e.g., needles and syringes at opposite ends of a clinic room

• Walking to equipment that is not centrally located, e.g., printer

• Searching for files on your computer desktop

Waiting

For people, signatures, equipment and/or information. It is a waste that cannot be recovered as it relates to time:

• Waiting for admissions from ED, ICU, theatres, etc.

• Delays for lab/radiology test results

• Waiting for discharge letters/prescriptions

• Patient back-up due to equipment not working properly

• Delays to fit staff schedules

• Excessive signatures or approvals required

Over-production

Producing more than is needed, or earlier than needed by the next process:

• Putting a patient on a waiting list

• Keeping investigation slots, ‘just in case’

• Delivery of samples, drugs, equipment too early or too late

• Entering repetitive information on charts or forms

• Repeating the same questions across multiple assessments

• Ordering more tests or services than what is required by the patient

• Producing reports that no one needs or reads

Over-processing

Putting more work or effort into the work required by internal or external customers:

• Retesting, for instance, doing same bloods and X-rays on patients who have had them done the day before by GPs

• Completing excessive paperwork

• Entering repetitive form information

• Repeated clerking before the patient is admitted to an inpatient bed

• Copying too many people into email distribution list

Defects or mistakes

Refers to all processing required creating a defect or mistake and the additional work required to correct it:

• Medication errors

• Adverse events, e.g., sentinel events/serious untoward incidents

• Wrong or missing information

• Adverse drug interactions

• Retesting due to inadequate sample, correct information not provided or wrong process earlier

• Out-of-date stock – often due to excess inventory

• Wrong patient, wrong site, wrong dosage, wrong time

Staff under-utilization

A result of not placing people where they can, and will, use their knowledge, skills and abilities to the fullest. It is, perhaps, one of the greatest wastes:

• Basing work on job title not competence

• Inadequate performance management system

• Rosters mismatched to patient workload

• Not using staff ideas

How many examples of waste can you identify where you work?

Linked to waste, and usually masking inventory waste, is an opportunity to create a cleaner, calmer and more pleasant work environment using 5S. Decades old, 5S as translated from Japanese are seiri (sort), seiton (set in order), seiso (shine), seiketsu (standardize), and shitsukie (sustain). 5S is the starting point of any lean improvement process. Combined with the seven wastes it is often misunderstood as being the purpose of Lean Thinking rather than the start of understanding and practicing lean production principles. The reader is encouraged to view Lean Thinking as a series of inter-related tools and methods designed to support continuous patient flow with the least time and resource requirement whilst achieving the highest quality outcome.

Each stage of the 5S process is specifically designed to transform the workplace and set in motion a culture of waste elimination (Hodge & Prenovost 2011). Box 42.2 defines and describes 5S.

Box 42.2 Applying 5S in practice

Sort

To get rid of non-essential items, make sure most frequently used items are close by. Sort enables the elimination of clutter and unwanted items that so often make an area feel unsafe, disorganized and hard to work in. Sort is completed in five steps.

Step 1: Ask yourself the following questions

Systematically go around the room/area sorting the clutter and dispose of or quarantine for later recycling/disposal

At the same time red tag items by asking the following key questions:

Is it needed?

How many are needed? Are there too few/too many?

Where should it be located?

Step 2: Identify how often the item is used

Frequently: Items used constantly (once a day, every hour (green tag):

• Keep them at the workstation

Sometimes: Items used often (at least once a week) (yellow tag):

• Keep within easy reach

Occasionally: Items needed from time to time (every few months) (yellow tag):

• Store them at a distance from the workstation

Rarely: Items Never/Not used in the last 6 months (red tag):

• Discard or move to the quarantine area

In practice, most places simply red tag

Step 3: Team review of the red tags

All staff review red tags over a 7-10-day period. Staff add a sticky dot if they disagree along with a comment to explain why.

Step 4: Validate the amount needed

How many of each item is required?

• You may need to validate the amount with a tally chart/inventory sheet

• Also obtain this information from stores

• Use the ward-based data to help inform your decisions

Set in order

‘A place for everything and everything in its place.’ It should take no longer than 30 seconds to locate any item. Whilst the red tags are being reviewed by staff, complete the following preparation to help clarify or answer their questions:

Step 1: Preparation

Collect background information related to the red tags as appropriate, e.g.:

• How many items or stock are needed? Relate this to number of patients or times the item will be used before it can be reordered rather than from existing stock levels

• Analyse the task that people use the items for and how people use them in the work area:

• activity tally sheet

• spaghetti diagrams (Fig. 42.2)

• Consider ‘relationships’ with other items, i.e., look at bringing equipment such as catheterization materials together if it is used in the one task and where is the best location for it in relation to its use

• Inform staff of findings to generate discussion and gain agreement

Step two (undertaken by the 5S Team)

Attend to every red tag in the work area:

• Discard those items which are no longer required, e.g., out-of-date stock. Capture cost of these items and/or photograph

• Quarantine those red tag items that are rarely/never used or while deciding on stock levels. Remove these items from the immediate area and store where items can be collected if required

• Establish locations of where things should be and reorganize the work area. Remember to arrange items to suit your processes and work flow

NB. Look with fresh eyes – challenge current practices.

Step 3: Establish visual controls with labelling

• Borders

• Home address – where does the item ‘live’?

• Identification label on each item

• Shadows

NB. It should be easy to identify if something is missing or not placed back properly.

Shine

Inspecting, maintaining and keeping the work area clean.

• Undertake a basic ‘spring clean’

• Create standards to keep it clean

• Create a 5S cleaning plan so everyone knows what needs to be cleaned and who is responsible for ongoing activities to keep the area clean

• Make it an everyday task so it becomes a natural part of the work, i.e., incorporate cleaning as part of completing the activity not something done at a later date

Shine ensures that broken equipment and clutter is identified and eliminated. Educate staff of the system to follow for broken equipment:

• Remove equipment from use and attach a label so others will not use it

• Note in detail the issues relating to the equipment failure

• Inform the relevant manager of broken equipment and/or

• Send requisition directly to Clinical Engineering/other department.

Standardize

Making different work areas with the same function the same, i.e., establishing ‘standard workflows’

The advantage of this approach is that Units can jointly agree on the order and location of clinical forms, stock items and clinical equipment, etc. This reduces the amount of time spent by staff looking for items and is helpful for staff unfamiliar with that particular unit.

Standardizing is about:

• Agreeing a standard

• Communicating the standard

• Documenting the standard

• Following the standard

Standards can be presented in many forms:

• Photos

• Guidelines and checklists

• Visual aids

• Make standards visual, e.g., labelling, colour-coding, min/max levels, etc.

Without a standard you can slip back.

Sustain: Driving continuous improvement

The final step is to ensure the process is more than just a big clean up.

• The final step to ensure the process is more than just a big clean up and the hardest!

• Naturalizing the activity as part of everyday work

• Monitor the area to ensure compliance – audits

• Continuous improvement (improve the standards)

Moving to flow

Conceptually patient flow is about moving the patient through a series of process steps in a continuous manner with no waits and delays between process steps and within processes.

There are two methods of moving patients through a health system. The first is to create batches of like patients, and the second is to create single patient continuous flow. In the emergency setting continuous flow is the predominant method; while in elective care and acute medical environments, batch processing tends to be the main method, which often as a result impacts on the discharge end of ED activity. A batch is created when patients are grouped together for an event such as assessment clinics, theatre sessions, ward rounds, imaging clinics, etc.

Every time a batch is created we create greater variation for the next process step, which in turn means it is more likely that a queue will form. In this way, we have become immune and accept internal queues and consider a queue as necessary to the efficient management of any health system.

An understanding of Lean manufacturing techniques teaches the impact that batching has on achieving timely outcomes for patients. In the manufacturing environment, the goal is to create ‘single piece flow’ where product is moved from one process to another process one at a time. In this way the total time it takes to get a product through a series of processes is reduced to the minimum.

In most businesses, including health, batches of products or patients are created. The larger the number of products or patients in the batch the longer it takes to get through a series of processes, and therefore the more likely an expediting process is developed to ensure an outcome is delivered on time. When an expediting process is implemented then effectively we are creating a prioritization process, or another unique product that disrupts the use of resources and flow of activity. Removing batches is the ideal goal, reducing batch sizes is the practical focus. For example reducing the number of patients per ward round will decrease the time it takes to complete tasks from the ward round, which in turn will shrink the time it takes to make the next decision for the patient. The next step is to then increase the frequency at which ward rounds are undertaken to remove any delay for the next set of decisions being made. This concept is about moving to continuous flow by reducing batch sizes; which supports the goal of valuing the patient time.

The goal of continuous flow is impacted on by fluctuations or variation in demand and resources. Lean Thinking seeks to smooth out variation and create consistent flow, from which work can be balanced between resource functions. Workload balancing concepts are not covered in this chapter, but need to be understood in conjunction with the following section on understanding variation.

Understanding variation in demand

For most patients their General/Primary Practice or ED team is their first contact when a health need arises. The quality of training and knowledge is very similar among these teams; but the knowledge of treatment options available within their health system varies significantly based on the relationships and exposure the teams have within the wider health community. This results in variation between clinicians as to how they refer patients between hospital and specialist care systems.

Variation in demand and capacity is the biggest cause of service failure. Having an understanding of demand variation is critical to developing strategies to eliminate queues such as waitlists for surgery. Many waitlist initiatives, such as cleaning up waitlists to remove demand that cannot be seen, or demand that exceeds capacity, fail because no change has been made to the causes for the waitlists developing in the first place. Waitlists or queues form because there is a mismatch between demand and capacity. Most queues form because there is significant variation in demand and variation in capacity which amplifies the gap between demand and capacity.

Silvester, Steyn and colleagues have studied the impact of variation on health services, and published a series of articles on the art of understanding and managing variation in the health system (Silverster et al. 2004, Walley et al. 2006, Allder et al. 2011). Their work is based, among other things, on Queuing Theory first developed by Agner Erlang, a Danish engineer in 1909 who worked for the Copenhagen Telephone Exchange to help the telecommunication industry to assign sufficient switchboard capacity to meet the majority of demand (Erlang 1909). Too much capacity would mean money wasted, too little capacity and calls would not connect. Queuing theory is the mathematical study of waiting lines or queues and is widely used in telecommunication, traffic engineering, computing, manufacturing and service industries and health.

The two key messages of this work are: reduce the causes of variation in demand and capacity; and then set capacity to 70–85 % of the variation in demand (see Box 42.3). It is important to note that understanding when to use 70 % versus 85 % is based on how much variation occurs in demand, and is outside the intent of this chapter.

Box 42.3 Establishing demand and setting capacity

If the number of patients being admitted to the ED daily for minors varies between 75 and 120 then the variation would be 45 a day. Using Erlang’s theory:

80% of the variation (45 x 80%) = 36

add the minimum daily attendances = 75

then the optimal patient volume to base capacity = 111

This means that every day the ED will have capacity to see 111 patients. Note there is a different set of questions to determine when this demand comes in, what mix of patients makes up the 111 patients, and lastly what does capacity for 111 patients mean; i.e., if 12 of these patients are trauma-related then the resources required need will be different to the 54 minor, 15 surgical and 30 medical patients.

Any process that has allocated capacity based on the average volume, will create a queue. If the size of the ED has been based on average daily volumes, then in theory 50 % of the time demand will exceed capacity; but in reality it will be higher than this as variation of staff availability impacts as well as the variation in demand.

Pulling all the flow elements together

When clinicians lead service improvements, supported by managers, the level of change can be significant and, as important, sustained. One of the authors (Ardagh) co-led a major reform of emergency department’s processes, plant and people. The case study of Project RED (Rejuvenating ED) can be found in Box 42.4.

Box 42.4 Project RED: improving flow in ED

In 2007, the ED at Christchurch Hospital, New Zealand, was suffering severe overcrowding. In response, three senior ED clinicians conceived and implemented Project RED (Rejuvenating the Emergency Department). The overarching principles of the methodology were that the project was: patient-focused, clinician-led, management-supported, action-orientated, prioritized, transparent and accountable. Principles of Lean Thinking, Theory of Constraint and Six Sigma were well known to the leaders of the project and pervaded its methodology.

The methodology categorized the project into people (staff), plant (space and other physical resources) and processes (ways of doing things). Under these headings an ‘Action Plan’ was populated with a number of problems and/or actions required to resolve problems. Each of the specific problems/actions was graded according to two dimensions: urgency (U) (based on assessment of degree of risk already present because of the problem); and importance (I) (based on the contribution resolving the problem would make to resolving the risk, and achieving the objectives of the project).

Under these two headings (U and I) each specific action was graded as either high (H), moderate (M), or low (L) level of urgency or importance. Specific actions were further graded under the heading of Time (T), according to whether the intended solution was a ‘Quick Fix’ (Q), because of an urgent need for solutions, or whether it would take longer to see results – slower to achieve (S) (or somewhere in between – Q/S). Some problems were addressed by more than one action with one addressing an urgent need and the other addressing the longer-term need, and proceeding in parallel.

The first Action Plan was large, consisting of many pages of concentrated actions. Initially, with so many things needing to be done, the project concentrated almost exclusively on the ‘HHQs’ (High Urgency, High Importance, and Quick to Achieve).

All ED staff were involved in defining the problems, the solutions, and their priorities. As a sub-project a ‘Lean Team’ was established in the ED, consisting of doctors, nurses, clerical staff, allied health staff and radiographers, to review processes within the ED that might be improved without recourse to people outside the ED. Meanwhile the ‘RED team’, consisting of ED clinicians and representatives throughout the hospital, worked on wider system issues including access to hospital beds, processes for moving patients out of the ED and pathways for management of specific patient groups.

Waiting times to see a doctor and length of stay in the ED improved significantly (Ardagh et al. 2011), but the more subjective outcomes of reduced ED overcrowding, infrequent corridor placement of patients, and improved staff morale were most appreciated by ED staff. Christchurch ED is currently in the top 1% of hospitals in New Zealand and Australia for shortest ED length of stay.

Conclusion

This chapter has outlined three key concepts:

1. Identify the goal: What is the service goal in your department? Is it related to time? And does it challenge us?

2. Understand value: what parts of the patient journey are value adding? Can we eliminate the non-value components to a patient’s journey, such as the waits and delays or repeated steps? What staff work is necessary and what can be reassigned? Should a staff member be expected to do certain work, have they been trained sufficiently and will it benefit the patient outcome? Understanding value can be challenging as we need to analyse what we do and impartially assess is this necessary or is it waste. Identify the seven wastes in the patient’s journey and in your work. Seek to eliminate as many wastes as possible.

3. Create flow: the ultimate goal is to create health outcomes at the rate the community needs them. Removing batches of patients from the system reduces variation and reduces the time to treatment and discharge. Any demand system will have natural variation, but most variation is created by us through poor understanding of demand and capacity, and poor process. Variation is the cause of most queues in health, and as such is the most misunderstood driver of health outcomes.

These are starting points to understanding how service design can best be improved. On their own they are not sufficient to achieving high performance; but should act as the guiding principles of any redesign of service.

A key concept of any redesign is to involve the whole health system in the design and improvement process; especially on creating flow. To improve ED service delivery requires a combination of partners from across the health system to ensure that the true system constraints are identified and fixed, which may involve the role of ED changing or the management of patient conditions changing (Holden 2011). Focusing the principles of this chapter on departments in isolation to the health system or patient journey across the health system, will limit the success and benefits of Lean methods.

Any process needs to understand demand and workload, and should seek to create standard workflow, or a common understanding of how work is done. Predicting demand has been well proven to work within health (Martin et al. 2010); translating this demand into capacity consumption or workload is a subject beyond the focus of this book. It is, however, a key consideration in designing patient flow, as the goal is to predict demand on the ED by shift and to translate this demand into resources such as beds, doctors, nursing, allied health, etc.

Patient safety, although not discussed in this chapter, is about two key concepts taken from Lean Thinking; error proofing and standard workflow. Creating work methods that minimize errors is the goal of error proofing. Standard workflow is about embedding this method into the work activity so it is the only acceptable way to perform any tasks.

Lastly, any patient journey study and improvement cannot be undertaken without the active involvement of the user of this system. Patient design sessions should be implemented to understand what the experience is like and consciously redesigning to maximize the value and minimize the non-value components of the patient’s journey to an appropriate health outcome. The user is very aware of time and places a value on having their time respected. However, the user is very rarely given the opportunity to discuss this aspect of healthcare, as they are grateful to the staff for achieving an outcome, even if it came with long waits and little awareness of what was going to happen next.

The goal of any health system is to create health outcomes in the least possible time, for all. As health professionals we are good at creating clinical outcomes for people, we know how to respond and to treat those in need; but how do we achieve these outcomes and does it respect and value time? Have we created a system and process built around our needs or the patient’s needs? Whose time do we value the most? Your time, your staff’s time, or the patient’s time?

Ultimately, it’s a matter of reframing our thinking to a whole systems view, and recognizing that while our time is busy and important, our patients’ time is scarce. Designing systems and patient flow around patient time will mean that access becomes less about ‘targets’ and more about delivering the access standards and quality care that we want for our patients.