Managing Variation, Understanding the Effects of

Carve-out, Scheduling and Flow

How do we manage variation in demand?

• Delay

• Forced booking

• Carved out capacity

Carve-out can be…

HugeNumber of doctors

Number ofappointmenttypes

2 week waitUrgentSoonRoutineUrgent follow-upRoutine follow-upSecretaryPost-op

Thousands of combinations

It is impossible tobalance the queues

The size of the carve out Number of

specialists432Sur

geon

1

432Phy

sici

an 1

5 Rad

iolo

gist

Number of appointmenttypes

Flexi-sig

Colonoscopy

ERCP

OGD

urgentsoonroutine

routine

urgent soon

routine

urgent soon

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73 queues

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Queue type A Queue type B

Is all carve-out bad?

• Capacity for urgent cases (prioritisation of patients)

• Subspecialisation• The issue is not to eliminate all carve-out, but

rather to eliminate unnecessary carve-out and reduce the impact of carve-out we can’t eliminate

TermsCarve-out When the flow of one group of patients is improved at one bottleneck at the expense of another group of patients

Streaming or segmentationSeparation of the process of care along the whole pathway for one group of patients to improve overall flow but not at the expense of other groups of patients

Analogy of segmentation and flow: traffic flow on motorway

Slow lane50 mph

Middle lane70 mph

Fast lane90 mph

All vehicles keep to same speed in allocated laneand all progress according to their need

What happens when lorry moves into middle lane at 55 mph?

Slow lane50 mph

Middle lane70 mph

Fast lane90 mph

• backlog of traffic• actual consequences are not seen at point of bottleneck

• flow rates compromised • few needs met

When is it carve-out?

• When ring-fencing resources for one group reduces resource available for another group

• How can we tell whether the problem is carve-out or capacity?

Demand exceeds capacity

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If Demand >Activity or Capacity

Numbers waiting will go up

Waiting times will go up

Carve out and churnNumber waiting is constant over time

But waiting times may not be

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If Demand =Activityurgent

routine

“Skimming off the froth”

Variation and carve-out

• Variation helps cause the waiting list

• Carve out makes it worse

• So what are we to do?

Match capacity and demand!

• Set the maximum waiting time to the time the most urgent referral can afford to wait – Do today’s work today– Do this week’s work this week– Do this month’s work this month

What do we want to achieve?

• Maximise Throughput• Treat the maximum number of patients with the

minimum amount of waiting

• How?

By keeping everymachine and person

working flat out

Utilisation = efficiency

Sweat theassets!

Wrong

Flow

• We need to optimise the whole process - not each individual step

• Don’t maximise utilisation, maximise throughput• Manage the flow

How long does a scan take?

• Multiple queues

• Multiple slot types» arthrogram» thorax with contrast» spine» thorax

• Eliminate the carve-out

Build new CT templatesPreparepatient

Scanpatient

Get offscanner

ReportFilms

TypeReport

20 minutes - “Quickie”

Preparepatient

Scanpatient

Scanpatient

Contrast

Get offscanner

ReportFilms

TypeReport

40 minutes - “Longie”

Monitor progress

CT Demand/Activity/Capacity and Backlog

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Matrix Allocation: Step 1Draw a matrix

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Condition 6

Condition 5

Condition 4

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Condition 1

Step 2Fill in the matrix

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Condition 6

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Condition 1 x

xx x

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x x x x x x

Ensure all conditions have at

least one consultant

x x x

x x x

Step 3Establish clinical care groups

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Condition 6

Condition 5

Condition 4

Condition 3

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Condition 1 x

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x x x x x xx x x

x x xccg 1

ccg 2

Step 3Allocate patients Patient with

condition 4

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Clinical caregroup 4

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02468101214161820222426283032343638404244Wait (weeks)

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Actual Outpatient Waiting List

Booked in Turn

Ophthalmology Outpatient Waiting List vs List for patients booked in turn

Scheduling

You cannot schedule your way out of a capacity problem...

What doesn’t scheduling do?

• Solve problems of a mismatch of capacity and demand

• Deal with unusual events

Define capacity and demand:

Capacity:

180 patientsper month

Activity:

160 patientsper month

Demand:

200 patientsper month

Backlog:

350patients

Scheduling will notresolve this problem

The solutions:

• Increase Capacity to match Demand

• Decrease Demand to match Capacity

• There are no other options!

Define capacity and demand:

Capacity:

240 patientsper month

Activity:

160 patientsper month

Demand:

200 patientsper month

Backlog:

350patients

But it might solvethis one...

An example of scheduling the bottleneck

Prepare bowelPreparepatient

Scope

Writenotes

Recover balance

Patient

Nurse

Endoscopist

Identify the- number of people- number of rooms- pieces of equipment available

2 loos for preparation1 theatre for scoping1 nurse for preparation1 scoper for scoping and writing notes4 recovery chairs for recovering balance

Flexi-sigmoidoscopy

Line up the templates

Only 1 endoscopist, so cannot start 2nd patient till endoscopist free

Only 2 loos, so cannot start the third patient until a loo is free!

What is the constraint? (defining capacity)

What is the bottleneck? (current limit on activity)

endoscopist can’t starttill lateWasted time

Only 4 patients done

What solutions can you suggest?

• Add another endoscopy suite

Add more toilets

Get patients to do the bowel prep at home

Fix the loos and set new templates…

11 patients done in the same time!

Appointment timesset so that the endoscopiststarts on timeSchedule the template

around the constraint

What are the risks?

• Some patients will not come fully prepared• They will have to be rescheduled to another day or

at the end of the clinic• Do not schedule to 100% utilisation of the scarcest

resource• Do you want to fly in a plane that is scheduled to

use 99% of the available fuel to get to its destination?

• Remember that capacity is 80% of the fluctuation in demand

The road to ruin:Capacity plans and contracts based on average past activity

Fail to deliver required activity

Income less than expected

Cost cuttinginitiatives

Fail to account for variation in demand

Reduces effective capacity

Guarantee waiting times beyond emergency and elective targets

Increase staff overtime & waiting list initiatives

Increased costs

Increased variations in capacity

Fail to account for variation in capacity+

The road to financial health

Capacity planning and contracts based on variation in demand

Income guaranteed Costs controlled

increasesproductivity

Required activityguaranteed

No waiting beyond emergency or elective targets

Staff capacity to reduce variation in capacity