Department of Human Services

Diagnostics and Constraints Diagnostics and Constraints TheoryTheory

Marcus Kennedy

Clinical LeadPatient Flow Collaborative

4th May

From project to habit…From project to habit…

• Themes of today:

– Reinforcing what we have learnt– Showcasing improvements– Making these effective methods part of

every day business

A storyA story

• Hospital x identified an ‘elective surgical throughput’ value stream– Access problems– Waiting list blow outs– Admission systems chaotic– Theatre bookings whimsical– Not meeting targets– Losing bonus dollars– Losing surgeons

HELP !!!

PFCPFC

Why Multidimensional?Why Multidimensional?

A. Because this was the NHS way?

B. Because Jenny Bartlett said so?

C. Because this way we could see and appreciate whole systems from all perspectives:– Organisational– Patient– Workers– To avoid tunnel vision and

myths

Theory of ConstraintsTheory of Constraints

…like a chain with its weakest link, in any complex system at any point in time, there is most often only one aspect of that system that is limiting its ability to achieve more of its goal. For that system to attain any significant improvement, that constraint must be identified and the whole system must be managed with it in mind…

The Five Focusing Steps of the The Five Focusing Steps of the Theory of Constraints (TOC) Theory of Constraints (TOC)

– Identify the system constraint. • Although a system will have many processes, few will represent

a constraint to the overall system. The more complex the system, the more likely it is that there will be a single, overall bottleneck

– Get the most out of the constraint • since it determines system throughput. The entire value of the

system is represented by what flows through the bottleneck. For instance, you would want to keep the bottleneck working all the time, since your whole system is idle if the bottleneck is idle

– Support the constraint • by making it only do work that cannot be done elsewhere

– Elevate it • within the system so that all other parts work to help it

– Return to step 1 • because a different process may have become the constraint

Constraint TheoryConstraint Theory

Hospital ‘x’ Identified Hospital ‘x’ Identified ConstraintsConstraints

1. Discharge incoordination due to registrar OR commitments

2. Booking system organisation3. Availability of fluoroscopy in OR

““Lean” approachLean” approach

• Understand Customers and what they value

• Define the internal value stream

• Eliminate waste, make information & products flow, pulled by customer needs

• Extend the definition of value outside your own company

• Continually aim for perfection

Terry Young, Sally Brailsford, Con Connell, Ruth Davies, Paul Harper and Jonathan H Klein, Using industrial processes to improve patient care BMJ 2004;328;162-164

Understanding the “wastes” Understanding the “wastes” of ‘lean’of ‘lean’

• Overproduction– Producing too much too soon, resulting in poor flow of information or the deliverable

and excess • Defects

– Frequent errors in paperwork, data and information, product quality problems, or poor delivery performance

• Unnecessary information or inventory– Excessive storage and delay of information or products, resulting in excessive cost and

poor customer service • Inappropriate processing

– Going about work processes with the wrong set of tools, procedures of systems, often when a simpler approach would have been more effective

• Excessive transportation– Excessive movement of people, information or material, resulting in poor flow and long

lead times • Waiting

– Long periods of inactivity for people, information or material, resulting in poor flow and long lead times

• Unnecessary motion – Poor workplace organization, resulting in poor ergonomics, eg excessive bending or

stretching and frequently lost items

I’m a textbook hero !I’m a textbook hero !

Solution to key constraintSolution to key constraint

• Event driven discharge• Patients went home .6 days

earlier• Capacity improved

• Therefore inspired by sweet success the team moved on and tackled the second constraint– Booking system organisation

Booking system Booking system improvementsimprovements

• Streamlined• Removed duplication• Single assessments• Removed paperwork• Automated messaging and contacts /

reminders

Impact = -273Impact = -27300 C C

Why is it so?Why is it so?

Shifting ConstraintsShifting Constraints

• Now that event driven discharge allowed shorter LOS

• Allied health services required on the day of discharge were unable to meet demands

Systems are dynamic beastsSystems are dynamic beasts

132

Initial constraint analysis

132

Post intervention constraint analysis

Complex SystemsComplex Systems

• We deal with complex, multiply intersecting and interdependent systems

• Not linear independent production lines

Chaos TheoryChaos Theory

• The relationships within these chaotic systems are not always initially clear

• Beware of assumptions (aka myths & preconceptions) : these are the inherent flaws of many of our less effective previous strategies– Continuous measurement

and analysis– Continuous Whole system

orientation

Repeat analysisRepeat analysis

• Repeat diagnostics / constraint analysis– Tailor– Refine– Embed methodology

• Actively revisit Lean Methodology interventions– Targeted at constraints– Beware fanatical / untargeted application in a

complex / chaotic system– Intervention theme not a new organisational

religion

Project to SystemProject to System

• Do something or nothing will happen• Current bed management + PFC = way to go• Executive links• Redefine TOR• Actively build in Constraint Theory & Lean

Thinking• Celebrate achievements

Data:Data:

• Selected (refined) data presentation of previous month and week

• Forecast data presentation for next week (based on historical/previous yr data and known current activity & threats)

Strategy:Strategy:

• Current Flow Improvement Strategies (presented in action table)– achievements since last meeting– challenges encountered in progressing plan– known threats for next week– plans for next week– actions points

Policy and Procedure:Policy and Procedure:

• review of flow policy and process breaches over the last week

• actions defined

Retain Methodological Retain Methodological ContextContext

• Review of Constraint Table (~Fortnightly)– Lists Organisational Value Streams, with identified

key constraints per stream and action priorities.– Identifies next actions re improvement and allows

forward planning of implementations.– Drives knowledge of constraint theory and lean

thinking methodologies

AnticipationAnticipation

• Review of Threats (~Monthly)– The month ahead is assessed with regard to

perceived threats to patient flow eg public holidays, staff changeovers, public events, conferences and other leave, known infrastructure changes, shutdowns or decrease in performance.

New Hospital Access TargetsNew Hospital Access Targets

• Tens of Million$– “Matters” to the base budget

• Achievement– Go harder and faster– Do something different – Those that have already implemented change are

advantaged

12 months down the track:

•Are expectations (culture) of flow different?•Are systems changing to achieve this? •Have we achieved all we needed to?•Have we got the right tools?•Have we learnt to use them optimally?•Will we get there?

Questions

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