achieving a breakthrough in health and social care using theory of constraints. patrick hoefsmit
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Achieving a breakthrough in health and social care using
the Theory of Constraints
Patrick Hoefsmit
27th September 2012
Innovative Developments in Operations Management
VilniusViešojo sektoriaus
efektyvumas
Agenda
• History of progress to date• Theory in practice
− Identifying and explaining the inherent simplicity
• What next for health and social care?• Evidence based research
Time
€
As the costs of medical treatment increases rapidly in comparison to growth of the available
budget
Why do we feel the problem is intensifying?
Budget
Medical costs
The Theory of Constraints, developed by Dr Eli Goldratt and described in his famous novels, focuses on achieving
breakthroughs in
performance in large, complex environments, dominated
by high uncertainty.
History of progress to date
• The starting point – “Yes, but will it ever work in the health environment?”
• Over 30 successful implementations in the UK, Holland, Australia and USA.
• To date, penetrated more than 10% of the UK acute health market
• Now have proven applications in emergency and planned care (emergency, discharge, operating theatres and outpatients).
• New research and implementations underway in mental health care and the wider social care environment.
Example resultsOrganisation Results achieved
Barnet & Chase Farm Hospitals NHS Trust
Length of stay reduced by 27%Emergency access improved from 90% within 4 hours to 98% within 4 hours
Frimley Park NHS Foundation Trust, England
Length of stay improved by 20% in one of the previously best performing hospitals in the UK.
St Maartenskliniek Nijmegen, The Netherlands
Higher quality and more timely treatment of outpatients without extra resources
Derbyshire Community Hospitals, England
30% reduction in length of stay in a matter of weeks
Amphia Ziekenhuis, The Netherlands 16-18% reduction in length of stay in 12 weeks and still improving
In times of fundamental transition, the first substantial actions of any major initiative must produce immediate substantial benefits.
When we started it took us eighteen months to produce ‘immediate substantial benefits’. The same project today will deliver bigger results in twelve weeks or less. Some implementations have now sustained and built on these improvement for more than seven years.
A customer’s view
“We have been able to move from one of the worst to one of the top performing Trusts in England. By working with QFI to apply the Theory of Constraints to our discharge process, we have been able to reduce our length of stay by 27% and we know we can improve on this. I have seen many methodologies but, putting it simply, the combination of the Theory of Constraints and QFI Consulting delivers results much faster than anything else around.” Averil Dongworth, Chief Executive
“We decided to invest in the QFI-Jonah approach as part of our broad-ranging strategy to reduce length of stay and I’m pleased to say that this overall strategy has produced very positive results with a reduction of more than 20% on those wards where QFI-Jonah is used”. Andrew Morris, Chief Executive
“We had a two-day meeting with Alex Knight and at some point in the second day I realised this must be the solution. It was quite a different view of how to manage an outpatient clinic. It was a paradigm shift because it is a completely different way of working.” Frank van den Hoogen, Lead Consultant Rheumatology
A customer’s view
“By working with QFI to apply their Theory of Constraints approach, we have been able to reduce our length of stay by a third within a matter of weeks and make big improvements to the quality of our patients’ rehabilitation and discharge. The process has developed staff’s confidence in their ability to take control and make changes which improve quality and productivity and has significantly improved multi-agency working across health and social care in Derbyshire.”Tracy Allen, Managing Director
With the start of the TOC-program, hospitals in the UK, USA and Australia were able to see their results in healthcare improve. This success was a reason why we worked with QFI, the developers of this simple Jonah-approach. Within a few months the first results were visible: the average length of stay decreased. A practical approach and not just a beautiful story in a book!Mary Groenewoud, Service Director
Theory in practice
- Identifying and explaining the inherent simplicity
HomeCommunity Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
Theatre
Outpatient Schedule
Emergency Department
Home
Assessment Unit
Home
MedicalUnit
Home
The Emergency Stream
GP Referrals MajorsMinors
Beds
KEY
Other non-bottleneck resources:
HomeCommunity Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
Theatre Schedule
Outpatient Schedule
Home
Beds
KEY
Other non-bottleneck resources:
GP Referrals
The Planned Care Stream
HomeCommunity Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
MedicalUnit
Theatre Assessment
Unit
Outpatient Schedule
Emergency Department
HomeHome
Home
GP Referrals MajorsMinors
Beds
KEY
Other non-bottleneck resources:
The System
GP Referrals
How to solve such a seemingly complex problem
The Five Focusing Steps
Step 1: Identify the system’s constraint(s)
Step 2: Decide how to exploit the system’s constraint(s)
Step 3: Subordinate everything else to the above decision
Step 4: Elevate the system’s constraint(s)
Step 5: If in the previous steps a constraint has been broken, goback to Step 1. Warning: do not allow inertia to causea system constraint(s)
Capitalising on the inherent simplicity of the system
To achieve a system wide breakthrough requires answers to these questions
• Of all the patients I could work on next, which one should I work on next?
• Of all the things I could change:– Where are the few places in the whole system I need to change?– What are the necessary actions to take in these few key places?– If I take these actions what will be the impact on the performance of
the whole system and over what timescale?– If I leave things as they are what will be the outcome?
The assumptions upon which the analysis can be conducted
• Dissect the system into manageable parts
Dissect the system into manageable parts
Outpatient Schedule
HomeEmergency Department
Home
Assessment Unit
Home
Mis-synchronisation, silo
mentality and local optima
conflicts, to name a few.
What are the drawbacks?
LOCAL OPTIMA DO NOT ADD UP TO GLOBAL OPTIMUM
The assumptions upon which the analysis can be conducted
• Dissect the system into manageable parts• Dissect the system into distinctive pathways
Community HospitalsHome
Community Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
MedicalUnit
Theatre Assessment
Unit
Outpatient Schedule
Emergency Department
HomeHome
Home
GP Referrals MajorsMinors
Beds
KEY
Other non-bottleneck resources:
GP ReferralsMajors
Emergency Department
Assessment Unit
Theatre
Surgical Unit
HomeSocial Services
→ Home
Dissect the system into distinct pathways
SpecialistUnit
Community HospitalsHome
Community Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
MedicalUnit
Theatre Assessment
Unit
Outpatient Schedule
Emergency Department
HomeHome
Home
GP Referrals MajorsMinors
Beds
KEY
Other non-bottleneck resources:
GP ReferralsGP Referrals
Outpatient Schedule
HomeSocial Services
→ Home
Dissect the system into distinct pathways
What are the problems with this approach?
• Key to success is improving the flow through the whole system
• Key resources that impact the flow of the whole system often work across many streams of the flow
• Improving any one stream of flow will not improve the whole system and can actually damage the flow through the whole system
Dissect the system into distinct pathways
The assumptions upon which the analysis can be conducted
• Dissect the system into manageable parts• Dissect the system into distinctive pathways• Dissect the system by resource type
HomeCommunity Hospitals
Social Services → Home
Surgical Unit
SpecialistUnit
MedicalUnit
Theatre Assessment
Unit
Outpatient Schedule
Emergency Department
HomeHome
Home
GP Referrals MajorsMinors
Beds
KEY
Other non-bottleneck resources:
GP Referrals
Dissect the system by resource type
What are the problems with this approach?
• Most resources are non-bottlenecks• Improving non-bottlenecks does not improve the
flow through the whole system• Saving money on non-bottleneck resources by
reducing capacity often creates a system of wandering bottlenecks, which can become a nightmare to manage
Dissect the system by resource type
Underpinning assumption: the more complex the system the more “inherent simplicity” that exists
• Identifying the inherent simplicity– Set a clinically-based treatment time for all patients– Sequence all resources to meet the clinically- based
treatment time– Identify which resource is most often causing the
most time delay to the most patients across the whole system?
– Focus ALL improvement efforts on this key resource – Initiate a process of focused system-wide
improvement
Time Buffers
Patient 1
Admission date
Clinically based Planned Discharge
DateMDT
This patient is in the red and the blue resource is the cause of the patient being in the red
Patient 5
Admission date
PDD 5MDT
Admission date
PDD 4MDT
Patient 4
Patient 3
Admission date
PDD 3MDT
Admission date
PDD 2MDT
Patient 2
Patient 1
Admission date
PDD 1MDT
Question: Which resource is most often causing the most time delay to the most patients across the whole system?
Answer: The blue resource is causing the most delay across the most patients! Would you like to know the size of the delayed days and which period of the week or year this is at its worse? By the way the blue department is already on the case and is following the updated sequence to overcome these delays. The Continuous Improvement teams are looking into offloading the blue and training up the red to avoid this problem in the future.
HomeCommunity Hospitals
Social Services → Home
Surgical Discharge
SpecialistDischarge
MedicalDischarge
Theatre Schedule
Assessment Unit
Outpatient Schedule
Emergency Department
GP Referrals MajorsMinors
Beds
HomeHome
Home
KEY
Other non-bottleneck resources:
GP Referrals
Buffer Buffer Buffer
Buffer
Buffer
BufferTheatre drum schedule
ROPE
Buffer
Buffer
Outcomes• Every patient has a plan and the status of that plan is clear
to everyone during the patient journey.• Every task manager has a clear priority list and is clear on
the impact they are having on every patients journey.• If a patient’s journey is being delayed it is clear who is the
primary cause of the delay and what recovery actions are necessary.
• At all times clinicians and managers know the size of the total delays across the system and the impact on current and future performance.
• Improvement efforts can be focussed on the resource causing the most delay across the most patients
• A sustainable breakthrough is quickly and safely achieved.
Complex systems
Seemingly complex systems do not require complex solutions.
Dissecting a seemingly complex system into its parts and analysing and improving the performance of each part will not improve the system as a whole
The more complex the system appears the more simple the solution must be.
What next for health and social care?
• Complete our work on key ingredients of success:– Solution development– Software development– Our own marketing development– Consulting capability development
• Build irrefutable evidence of success in more countries
• Document and publish
Revenue
Time
€
The revenue increases faster than The growth in medical costs
A true breakthrough
QuestionsThank you