What knowledge can we glean from our past and other work being done?

1. Information for ImprovementWednesday 18th November 2009Laurence KeenanImprovement & Support Team

2. What knowledge can we glean from our past and other work being done?

3. What do we know? • There is a lot of waste in the system • There is too much variation in the system • Parts of the system do not talk to each other

4. Presentation Admitted Discharged Pre-op assess Referral Put on Waiting list Clinic Clinic Clinic Operation Tests 18 weeks Follow up Ad infinitum The elective process

5. 18 weeks Follow up Ad infinitum More processes! Admitted Put on Waiting list Discharged Presentation Referral Pre-op assess Clinic Clinic Clinic Operation Tests • Doctor requests ‘test’ • Porter picks up request • Porter delivers request to department • Clerk logs request • Clerks puts request for prioritisation • Consultant for prioritises request • Consultant returns request • Clerk files request in priority order • Clerk draws request from file • Clerk makes appointment • Clerk sends appointment by post (>6 steps) • Patient receives appointment • Patient travels to hospital • Patient finds car parking slot • Patient finds X-ray department • Patient checks in at reception Adding Value or Waste??

6. Staff Skills Illness Motivation Shifts Holiday Training Patients Age Race Sex Motivation Disease Education Process Unclear Guidelines differ Complications in anaesthetics Discharged GP Machines not the same Supplies Rooms not the same Equipment Transcription Transport Applications Information 80% is within our control!! Sources of Variation that impact on patient flow

7. What Variability? – GP Practice • Number of patients • Number of problems • Investigations • Length of appointments

8. What Variability? - Outpatients • Number of referrals • Number of staff • Investigations needed • Length of consultation

9. What Variability? - Ward - Length of pre-admission stay - Length of post-op stay - Intensity of nursing required - Staffing levels

10. What Variability? - Theatre • Number of cases • Length of cases • Anaesthetic time • Recovery time • Turnaround time

14. Why is it important to understand variation? • Because the mismatch between the variation in demand and capacity is one of the main reasons that queues occur in the NHS ‘Good management is all about reducing variation’ Deming

15. Queue Capacity Demand time If average Demand = average Capacity the variation mismatch = queue Can’t pass unused capacity forward to next week

16. THE FLAW OF AVERAGES Capacity Plans and Contracts based on AVERAGE past ACTIVITY Fail to account for variation in DEMAND Fail to account for variation in CAPACITY Increased Variations in CAPACITY Waiting Times beyond emergency and elective targets Fail to deliver required ACTIVITY Reduces effective CAPACITY Increase Staff Overtime and Waiting List Initiatives PERFORMANCE less than expected Cost cutting initiatives Increased Costs

17. Understanding variation Every process displays variation • Common Cause Variation • Stable, consistent pattern of variation • “chance”, constant causes • Special Cause Variation • “assignable” • “pattern changes over time”

18. Analysing Variation with SPC • Statistical Process Control – what is it? • Measurement for Improvement • Not Judgement • Better way for making decisions • Evidence based management • Easy and sustainable • But it is only a tool, providing questions for us to investigate and answer!

19. Statistical Process Control • A control chart – similar to a basic run chart but with control limits • Helps to recognise variation • Helps to drive improvement • Has the process really improved, or is it just chance? • Is it sustainable? • Prove / disprove assumptions and misconceptions

20. Statistical Process Control Distribution of weekly waiting times (e.g. 1000 patients waiting) 3SD 180 3SD MINUTES

24. Consequences of not understanding Variation • We will see non-existent trends • Blame/credit non responsible individuals • Build barriers, decrease morale, create fear • Cannot: • Fully understand past performance • Make predictions • Significantly improve

27. SPC Questions • What is the reason for “Special Cause”? • Is a process acceptable just because it is ‘stable’ or should it be improved? • What should be done to improve a stable process?

28. Waiting list, queue = what we should have done Demand = All requests for a service = what we should do Capacity = what we could do Activity = what we did Demand, Capacity Activity & Queue

33. Benefits of applying DCAQ • Improve patient flow • Reduced waiting times • Improved capacity planning • Better utilisation of services • What else needs to be considered??

34. Improving the elective process with DCAQ? GP Out Patient Diagnostics In Patients • Increased Patient Flow • Reduction in Queues DCAQ Work in OP = • Increased Demand • Longer Queues Impact

35. Improving the elective process with DCAQ? GP Out Patient Diagnostics In Patients • Increased Patient Flow • Reduction in Queues • Increased Demand • Longer Queues DCAQ Work in Diagnostics = Impact

36. Summary - What do we need to do? • We must identify the duplication and waste and eliminate it • We must deal with the system as a whole, rather than a series of disconnected parts • We must understand and control variation across all processes (SPC) • To do this we must measure and monitor, Demand, Capacity, Activity & Queue