MANAGEMENT: PRODUCTIONFLOWANALYSIS

Productionflowanalysis:A toolfordesigningaleanhospital

SAULI KARVONENMANAGEMENTCONSULTANTANDMANAGINGDIRECTOR,SKA-RESEARCHOY

DRHEIKKIKORVENRANTAPROJECTLEADEROFFUNCTIONALPLANNINGOFT-HOSPITALANDASSOCIATEPROFESSORIN

PEDIATRICS,TURKUUNIVERSITY

MIKAELPAATELALEADINGARCHITECTANDMANAGINGDIRECTOR,ARKKITEHTITOIMISTOPAATELA-PAATELA& CO

TIMOSEPPLPROJECTLEADEROFCONSTRUCTIONIN THET-HOSPITALPROJECT,TURKUUNIVERSITYHOSPITAL

Expertsagreeon the need for a widespreadsystemredesignin healthcarel.An ageingpopulation,amongother things, will present hospitalswith a newproductivity challenge.System-engineeringtaols havedemonstratedsignificant potential for health caredevelopmeneandmodemresearchtechniquesarerequiredfortheplanningofhospitalsforthefuture"''.

Organisationalbarriersplayan importamrolethatrestrictsthe implememationof new designsin hospitals.Within ahospiral,individualdepartmentsare usuallyisolatedandbehavelikefunctional"SilOS".2Becauseof this,hospitalsaretypically based on functional organisations.Processorganisation4and process-focusedorganisationSare bothactuallysynonymsforfunctionalorganisation.With suchaset-up, units specialisein theirown particularprocessesandfacilitieswith similar functionsare groupedtogether.4.s.6Traditionallyhospitals'functionallayoutssupportthisconcept.7Laboratories,medicalimaging,operatingtheatreunits,andimensivecareunits,aswellaswardsareexamplesoffunctionallayoutsolutions.Thedisadvanragesof functionalorganisationare long throughputtimes,poor overallprocesscontro!:6

complexpatientflows,andlongtransferdistances.8ManyUKhospitalstransferpatientsfromoneunittoanothervialengthyand complexroutes.9Schedulingand the achievememoffluempatiemflowis difficultin suchhospitals9

In productorganisationor cellularmanufacturing,widelyusedin modemindustry,productioncellsor linescompleteproducts,astheyhaveallthefacilitiestheyneedtadoSO.+,lO.11The productof a hospitalis a treatedpatiem- not an

Code0EIKMNPQRTU

ProcessStrokeunitIntensifiedmonitoringInvasivecardiologyHomeIntensive ca re u nit

CardiaccareunitEmergencyNeurologywardRadiotogyMonitoringUltrasoundexamination

MANAGEMENT: PRODUCTION FLOW ANALYSIS

1234567891011121314151617181920

Numberofpatients1,2001,00070051750050033325850016780673333332017171786,000

patientflowsystemsta helpin theplanningaf a new,acutehospital.PFA is apragmatictechniquethathasbeenusedtapIan a changefrom functionalorganisationta productorganisationin industry4,1O,1lBurbidgealsodefinesPFA asatechniqueforplanningthesimplificationaf thematerialflowsystemsfor factories:In thispaper,we haveusedcare-lineorganisationasasynonymforproductorganisation,Thetermsaf productorganisationarebasedon an industrialframeafreference.The termsaf care-lineorganisationbetterillustratethisorganisationmodelfromahealthcareviewpoint.

Case study:Turku UniversityHospital IT-HospitaL]PFAwasusedinastudyafthepatientflowsbetweendifferentunitsaf a new,acutecarehospital;theT-Hospitalin Turku,Finland,Thehospitalwill becompletedin 2011.Our targetwastastudyandsimplifypatientflowin thehospitalby PFAin orderta achievetheadvantagesaf care-lineorganisation.Currently,thehospitalis functionallyorganised.

The patientflowswereanalysedtagetherwith the keypersonnel af the five main care-lines (cardiology,traumatalogy,neurology,surgery,and othermedical(non-surgicaDtreatment).AlI patientflowdataisbasedonthecare-lines' evaluationsaf increasesin patientvolumesbetweennowandtheyear20II. Followingthis,emergency,radiology,laboratary,intensivecare, operatingtheatreunits, andmaintenancegavetheircommentson theroutedata.PFA'ssubtechnique,factoryflow analysis,was adaptedinto thestepsaf theproject:Thepatientflowafeachmaincare-linewasanalysedbythefollowingsteps:

PRNKPRPQKKPKKPRPEQKKPRPDRDUDQKKPRPKKPRPTQKKPRPDRDUDQKKPRPDRDUDUDQKKPTKKPRPDRDUDUDKKPRPMEQKKPRPDRDUDIDQKKPRPDRDUDUDIDQKKPRPDRDUDNDQKKPRPDRDUDEDQKKPRPMQKKPRPDRDUDUDNDQKKPRPDRDUDUDEDQKKPRPDRDUDMDQKKPRPDRDUDUDMDQKlIumborofpalionls

individualoperationor examination.In hospitals,productorganisationmeansthatall staffandappliancesusedin thetreatmentaf illness are grouped tagetheras a multi-professionalgroupthatcompletespatient'scare.Therefore,productorganisationsupportspatient-andtreatment-focusedhealthcare.Thewellknownbenefitsafproductorganisationinclude quickerthroughputtimes,betterquality,smallerinventories,andsmallerinventory-carryingcosts4,IO,in additiontabettercontrollabilityafoverallprocesses:.61OIn theUK, theNational Health Serviceaccentuatesthe eliminationaf

unnecessarypatienttransfersandareducedriskafdelaywhiletransferringthepatientta anotherphaseaf careasbenefitsaftheproduct-basedlayoutin highvolumepatientcare.?

The objectiveaf this paper is ta demonstratehowproductionflowanalysiscanbeappliedtaanalyseandsimplify

A. Analysis:1.Codeprocessesin thecare-lineidentifiedwithacodeletter(Table1).

2. Findingprocessroutecodes(PRC)forallpatients.3. PrintingoutthePRCfrequencychan(Table2),4. Calculatingthenumbersaf patients'transfersbetween

processesandprintingoutthefrom/tachan(Table3),S. Drawinga patientflow networkfor 2011, basedon

functionalorganisation(Figure1).6. Drawingaprimarypatientflownetworkfor2011,based

TOD E I M II P '1 R T U :!:internaitransfers home:!: tutal

Strokeunit(D) 50 100 25 50 1000 1500 2000 4725 500 5225

intensifiell monitoring(E) 50 780 830 830

'mrnsivetardio'o!IY(1) 100 100 100

Intensivecare(M) 25 80 20 125 125

Cardio'ogit monitoring(II) 50 50 50

_0 Emergency(P) 1500 700 100 1200 4500 1000 9000 1500 10500

M lIellrolo!IYward ('1) 3500 3500- Radio'o!IY(R) 1500 4500 6000 6000-- Monitoring(1) 500 500 500 1000

Ultrasounllexaminiltion(U) 2000 2000 2000

:!:interna'transfers 5225 830 100 125 50 4500 3500 6000 1000 2000 23330

home(K) 6000 6000

:!:tutai 5225 830 100 125 50 10500 3500 6000 1000 2000

MANAGEMENT:PRODUCTIONFLOWANALYSIS

I I

II

on functionalorganisation.Primaryflowis basedon theParetoprinciple,inwhich20%ofthePRCscovers80%ofthecareline'spatients(Figure2a).

B. Synthcsis:7. Drawinga streamlinedprimarypatiemflow networkin2011,basedon acare-lineorganisation(Figure2b).

The Figures1 and2arepresemneurologypatiemflowsinfunctionalorganisation.The patiemflow systemnetwork(Figure1) coversall the neurologypatientswho use 20differemprocessroutes(Table2).However,patiemflowsareconcemratedin a few processrouteswhich composeaprimary patiem flow. Figure 2a represemsneurology'sprimarypatiemflowin which 80%of thepatientsusethesevenmostimportamprocessroutes(PRNs1-7in Table2).Back-flowsbetweenradiologyandemergency,radiologyandthestrokeunit,plusultrasoundexaminationsandthestrokeunitreduceefficiencyandriskpatiemsafety.Thetargetsaretaeliminatetheback-flowsandplacetheprimaryflow'sunitsnexttaeachotherorjoin someof theunitstagether.

The streamlined patiem flow model in care-lineorganisationis presemedin Figure2b. The streamlinedpatiemflowmodelwouldreduceneurology'spatiemtransfersbetweendepartmentsbynearly70%(from23,300transfersta7,300).Thestreamlinedpatiemflowrequirestheeliminationof the back-flows(Figure2a) by the decemralisationofultrasonicexaminationandothermedicalimaging.Thus,theemergencyunithasitsownradiologicalfunctions(Rad1);theunnecessaryboundarybetweenemergencyandradiologycanbe eliminated.Similarly,the stroke unit has its ownultrasoundfunctions,and the CT imagingIMRl(Rad2)are

~'

placedimmediatelynextto thestrokeunit.Streamlinedflowcan be largelyimplememed.When the streamlinedflow(Figure2b) is comparedwith taday'sflow (Figure2a), thestreamlinedflow providesthe followingbenefitsfor acuteneurologicalpatients:... Qualityofcarecanbeimprovedbecausepatients'

unnecessaryandpotemiallyriskytransfersarereduced.... Directpersonnelcostsavingsbecausemuchfewer

personnelareneededforpatiemtransfersbetweenthestrokeunitandradiology(ultrasonic,CT orMRl).

... Developmentof teamwork,whenmostof resourcesneededin thepatiemcarearelocatedclosetaeachother.Betterteamworksupportscominuouscareprocessimprovement.

... Indirectcostsavings.Thefollowingfactarscomributetaindirectcostsavings:i. Thedelaysanderrorscausedbytransfersareeliminated.ii. Nursesspendtheirworkingtimein thestrokeunitand

not transportingpatients,their productivitycan beincreased.

iii. Eliminationof referralsbetweenunits- referralis nota

value-addingactivity.iv.Thetransferappliancecostsandlift loadarereduced.

Thefourothermaincare-lineswereanalysedin thesamewayasacuteneurology.Thenallmaincare-lines'PRCsweresummedup and the emirehospital'sfrom/tachartforprimarypatiemflowwasprimedout. The primaryandstreamlinedpatiemflowsof themaincare-linesandthehospital'sprimaryflowswereessemialinforrnationfor thelayoutplanning.

Conclusion

PFA is a substamialtaol for acutehospitallayoutplanning,wherehighvelocitypatiemflowis a criticalgoal.This typeofanalysissupportssuch planningby indicatingwith good

certaintywhichfunctionsshouldbeplacednexttaeachother.PFA challengesthe prevailingpracticesof functionalorganisationandoffersa startingpointfor streamliningthepatientflowsystem.PFA illustratesthecomplexpatientflowpattemin functionalorganisation.

A notablefindingis the dominantpositionof medicalimagingwithin all fiveof themaincare-lines'primaryflow.Medicalimaginghasa centralroleatbothendsof thecareprocess;at thebeginningin theemergencyunit andat theendin thewards(e.g.neurologycase,Figures1-2).Medicalimagingshouldbeubiquitausin anacutecarehospital.Thiscanbeachievedbywell thought-outdecentralisation,whichcontradictstheprevailingprincipleof functionalorganisationthattendsta centraliseimagingfacilitiesundertheradiologyfunction.In care-lineorganisation,theimagingfacilitiesarelocatedin closeproximityta care-lines'needs.ThiscanhalfpatienttransfersbetWeenunits in an acutecare-hospital;transferdistancescanbereducedby morethan50%.In the

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MANAGEMENT:PRODUCTIONFLOWANALYSIS

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