Parallel Session 3.2 Innovations in Acute Flow and Capacity Management

3.2 Innovations in Acute Flow and Capacity Management

Session Outline• Working definition

• How we have prioritised flow

• How we might want to think about flow in future

• What are the issues – why raise our ambition?

• Celebrating our existing work & what it tells us

• Next Steps

Flow

1. a. To move or run smoothly with unbroken continuity, as in the manner characteristic of a fluid.1. b. To issue in a stream; pour forth: Sap flowed from the gash in the tree.2. To circulate, as the blood in the body.3. To move with a continual shifting of the component particles: wheat flowing into the bin; traffic flowing through the tunnel.

Right treatment areaRight time Right teamRight care

(as efficiently as possible and within available resources)

Flow = People

How we traditionally consider flow

• Access targets and standards (point improvements)• Evolved from point improvements to pathway

management (unscheduled care / 18 weeks RTT/ cancer/mental health)

• Chunking up strategies and goals for the system (i.e. elective and unscheduled)

• Focus on improving constraints (delayed discharge)• Strategies having competing impacts (patient boarding)• Insufficient emphasis on individual patient experience?• Insufficient recognition of workforce design on flow and

of improvement and workforce relationship?

How we should consider flow?

– Access/equity – safety issue– experience – efficiency

– 20/20 Vision demands on acute services are such that optimising throughput is critical

– Poor flow and inefficient use of capacity can drive up costs and may be compromising efficiency in all parts of the system

Efficiency & Productivity Framework SR10Aim, Objectives & Scope

“To improve the overall quality and efficiency of NHSScotland while ensuring good value for money

and achieving financial targets.”

Key objectives:• Quality is not compromised,• NHSScotland will achieve financial

balance over the SR10 period,• NHS Boards are supported in

achieving efficiency targets and improving services, and

• Central co-ordination of support, monitoring, benefits realisation and challenge will be available to NHS Boards.

Acute Flow & Capacity work-stream formed to support NHS Boards to improve/optimise flow and to challenge unwarranted variation.

Productive Opportunity (based on

McKinsey DoH study and applied pro-rata up to £300m)

The Problems of Patient Flow – Why raise our game?

Marilyn E Rudolph

• Peaks and valleys• Resource utilisation• Internal diversion – boarding• Increases in medical errors• Delays in patient care• Boarders and ED diversion (non IP areas)• Left without being seen• Decreased throughput = increased costs?• Increased length of stay• Staff and patient satisfaction

Theory: The Quality Pyramid

How Complex?

Reform agenda domains Medicalclinicians

Medicalmanagers

Generalmanagers

Nursemanagers

Nurseclinicians

Recognise interconnectionsbetween the clinical andResource dimensions of care.

Ambivalent Accept Stronglyaccept

Accept Stronglyreject

Adopt a perspective thatbalances autonomy withtransparent accountability.

Reject Accept Strongly accept

Accept Ambivalent

Participate in processes that areoriented to bring clinical workwithin the ambit of workprocess control.

Strongly reject Stronglyreject

Accept Accept Accept

Accept the multidisciplinaryand hence team-based natureof clinical service provision.

Reject Ambivalent Accept Stronglyaccept

Accept

Born this Way? People and Reform

Peter Diegling

National Results & Examples of Flow Improvement across NHS Boards

50%

60%

70%

80%

90%

100%

Jan

-11

Feb

-11

Mar

-11

Ap

r-11

May

-11

Jun

-11

Jul-

11

Au

g-1

1

Sep

-11

Oct

-11

No

v-11

Dec

-11

Jan

-12

Feb

-12

Mar

-12

Month

Pat

ien

t jo

urn

eys

wit

hin

18

wee

ksElective Performance:

% of Patient Journeys within 18 Weeks

0

20

40

60

80

100

120

Mar

-08

Jul-0

8

Nov-08

Mar

-09

Jul-0

9

Nov-09

Mar

-10

Jul-1

0

Nov-10

Mar

-11

Jul-1

1

Nov-11

Mar

-12

Quarter ending

Wai

t (d

ays)

Median (days) 90th percentile (days)

Median and 90th Percentile Waits for IP/DC

3525

105

63

4 Hour Emergency Standard Compliance

Emergency Care Pathways

Elective/Unscheduled Admissions by Day of Week

Variation within our Control?

Smooth Elective Flows?

NHS Board Examples

NHS Tayside: Exploring Improvements for Effective Management of Capacity and Demand

• Demand activity calculated for each medical specialty• Reason code tracker completed by each Specialty to ascertain reasons why

capacity not achieved• Reason code tracker includes: Patients on EDISON / Patients due for

discharge who are placed out with speciality ward for non clinical reasons / Awaiting script / Awaiting tests/investigations (state what) / No bed in receiving hospital

• Improvement methodology applied to tailor improvements to each Specialty• Development of Capacity and Flow page on staff intranet which has daily

activity info, RAG status for each directorate/CHP, access to escalation plan and action cards

• Developing a 7 day acute physician delivered service model to ensure senior clinical decision making at the front door

• Interactive whiteboards with real time information

•

A&E

Ad Unit

Sp Beds

CommunityBeds/IRT

NHBeds

Home

~60230/250

8.8(6) pts/d

Queue52 (62)

Waits4,8,12 hrs

QAssess.

~20

QAssess.49(49)

QAssess.

~18

Add. Capacity/ Boarding

31 (52)

Slow

15/6/2012

7.7(6.4) pts/d

~46/d

Improving Flow and Emergency Access Programme• Work streams = Front Door, Acute Admissions and

Specialty Flow, Community Flow

• Metrics and PDSA’s in each work stream

• Front Door examples –• Flow 1 and 2 / 4 hours • Fast track triage (time to 1st assessment)• Junior check in with Cons (referral rate /

clinical safety)• Specialty Review (time to specialty review)• Increased Consultant cover at peak times

(overall performance at 4 hours)

NHS Fife

NHS Greater Glasgow & ClydeManagement of Inpatient Flow

Glasgow Royal Infirmary

– Creation of Emergency Receiving Complex – patients streamed directly to the following areas :

• Minor Injury Unit• ED Majors and Resus• Medical Assessment Unit – GP referred medical patients go

directly• Impact of the above has demonstrated a significant

reduction in breachers and in particular breach reason “wait for bed”

NHS Greater Glasgow & Clyde

ED 4 Hour Breach Reasons by month: October 2010 - April 2012

0

100

200

300

400

500

600

700

800

Oct

-10

Nov

-10

Dec

-10

Jan-

11

Feb

-11

Mar

-11

Apr

-11

May

-11

Jun-

11

Jul-1

1

Aug

-11

Sep

-11

Oct

-11

Nov

-11

Dec

-11

Jan-

12

Feb

-12

Mar

-12

Apr

-12

Mo

nth

ly E

D 4

hr

Bre

ach

es

99 Not Known

98 Other reason

08 Major incident

07 Clinical reason(s)

06 Wait for 1st assessment

05B Wait for diagnostics test(s) - awaiting results

05A Wait for diagnostics test(s) - to be performed

05 Wait for diagnostics test(s)

04B Wait for initial A&E treatment - to be completed

04A Wait for initial A&E treatment - to commence

04 Wait for initial A&E treatment

03C Wait for a specialist - Wait for Mental Health/Psychiatrist

03B Wait for a specialist - Wait for Medical Specialty

03A Wait for a specialist - Wait for Orthopaedics

03 Wait for a specialist

02 Wait for transport

01 Wait for bed

NHS Board NHS GREATER GLASGOW & CLYDE Hospital GLASGOW ROYAL INFIRMARY

Month

Breach Reason

Source: ISD A&E2 datamart Management information Reports covering October 2010 - April 2012. Data is for management information purposes only and subject to change.

Note: When choosing board to view, do not choose '(All)' as will double count. Select NHS Scotland as board if wanting to view Scotland level data.

NHS Greater Glasgow & ClydeManagement of Inpatient Flow

Use of Lean methodology

• Three teams configured to work at Western

Infirmary; Royal Alexandra Hospital; Victoria Infirmary to :

– Improve discharge process with increased number of beds available before midday

– Improve flow through ED/wards by addressing relationship issues between Medicine and DME

NHS Lothian

• Implementation of Real Time Demand and Capacity Management (Resar, et al, 2011)

• Estimate of 10-15% in day capacity gains through implementing this methodology

• Project/Improvement Manager in place, estimate 6 months for implementation, further 6 for sustainability

• Focus on ‘Discharge Huddles’ and change in bed meeting process – accuracy of predictions – key issues to ‘unblock’

What the World of Improvement Science says….

Strategies for Managing Patient FlowS,G.Vaswani, M.C.Long, B.Prenney, E,Litvak

• Key principles:– System-wide not silos– Science-based, data-driven– Right structure before improving micro-processes– Compliance review and enforcement

• Operations Management– Critical path – minimise delays– Queuing theory – mismatch between demand and

resources– Simulation

Natural Variability

• Random • Predictable• Can not be eliminated (or

even reduced) • Must be optimally

managed

Artificial Variability

• Non-random • Non-predictable (driven

by unknown individual priorities)

• Should not be managed, must be identified and eliminated

A. N. Other Hospital

• Overcrowded

• Safety?

• Experience?

• Waits/Boarding

The Natural Variation

Hospital

– Emergencies only– Queuing theory to decide size

and staffing– Run at 80% capacity

The Artificial Variation

Hospital

– Electives only– Smooth all admissions and

discharges– Run at 95% capacity


• Artificial Variability– Inadvertence e.g. LoS in HDU awaiting bed– Provider scheduling – ‘dysfunctional scheduling of

elective admissions’– Inappropriate management of flows

emergency/elective predictions, complexity • Effects

‘Artificial variability cannot be predicted or managed but must be investigated and eliminated’– Compromised quality of care– Decreased patient satisfaction– Decreased staff satisfaction– Operational inefficiency/ high cost of care


• Variability Methodology

Peaks in scheduled admissions is artificial variability

caused by dysfunctional scheduling of elective admissions– Identify variability– Classify as natural or artificial– Statistical test for randomness– Quantify – as deviation from ideal expected pattern– Eliminate/ significantly decrease– Manage natural variability by stratifying patients


• Variability Methodology IHO– Eliminating variability where you can– Optimally managing it where you can’t– Different types of variability in health care

• Clinical variability – illness and response to treatment• Flow variability – when• Professional variability – time taken


Phases • Separate flows• Smooth elective and queuing theory to emergencies• Once optimised estimate resource for system

20/20 A Balanced Flow Hospital

• Flow = Quality

• Separate Flows

• Variation Smoothed

• Real Time Queuing Theory

• Whole System with Integrated Community Teams

Intelligent Flow

• Making the flows/processes visible/separating them• Measurement & balancing measures• Patient experience & co-design• Complex adaptive thinking – the whole system• Counter-intuitive - most variation is in elective care and

is a supply not a demand problem• Generating the evidence base that poor flow is a patient

safety, efficiency and experience issue• Sustainable improvement will require a focus on quality,

workforce and governance

Whole Hospital Acute Flow and Capacity Management

NHS Scotland’s Focus on Flow

Key Improvement Messages

• Separate scheduled and unscheduled patient flows • Eliminate / minimise artificial variability wherever possible • Assign separate resources for scheduled and unscheduled

patients • Resources for unscheduled patients should be based on

clinically driven maximum acceptable waiting times – match capacity to the profile of demand

• Resources for scheduled patients should be based on maximising patient throughput and minimising unnecessary waiting

• Only after separation and matching capacity to demand examine fixed resources

Next Steps - 2012

• Acute Flow & Capacity Management workstream progresses improvement projects and maintains close links to unscheduled care groups. Overarching improvement context

• Acute Flow & Capacity Management Programme Board receives proposals to test/implement a whole systems approach to flow and capacity planning – August 2012

• HSCMB, QAB and Efficiency Portfolio Board invited to agree proposals

The Relationship between Flow, Quality and Cost

Thanks to

Question:

• If Patient Flow slows down:– do more patients die? – does cost go up?

Agenda

• Programme Structure • High level measures

– What are we trying to improve?• Patient Flow

– Emergency and Elective• The constraints• The policies that need changing

• How to make changes happen

Structure for an Improvement Programme

Board

Flow

Functional Departments

Support functions

Planned careEmergency

Clinical subspecialtiesMedicineSurgeryPaediatrics

HR SuppliesEstatesFinanceIT

Pathology PharmacyRadiology Theatres WardsClinics Therapies

Board

DH, SHA, Monitor, Health Commission etc.

A&E

Transport

GP GP

Ambulance

Intermediate careCommunity hospitalsLong term care

Seattle Children’s Hospital

Board Report

Comments?

Weekly A&E performance & crude death rateApril 2007 to Feb 2011

Non elective deaths / non elective discharges inc deaths by Date of ADMISSION

Weekly number of A&E breaches

Non elective death rate

Comments?

Dec 07 Dec 09 Dec 10Dec 08Foundation Status deferred

What happenedIn Sept 2009?

Adult Non elective Rami(Rate Adjusted Mortality Index) (excl paeds, obs & midwifery)compared to average for peer group

Infection controlPalliative Care excluded > %15-64 years

admissions

Weekly Flow Cost Quality

Ap 07 to Ap – Jan 11A&E breaches &Non elective deaths / dischargesby date of admission

Total Pay costs(elective and non elective)Agenda for change

RecruitOpen new wards

Foundation Status deferred

Whathappened inSeptember 2009?

Comments?

What have we learned?

What the Warwick and Sheffield teams learned

• Plot the dots!– weekly data – reviewed monthly: Board

• Monthly 2 hour meeting:– Executives, senior clinicians and Dpt. heads from

across the health & social care system • Study, Adjust, Plan, Do

– When did the statistically significant changes happen?– Why?

» What did WE change?

Understanding Flow

Board

Flow


Support functions





Board


A&E

Transport

GP GP

Ambulance


High Level Emergency System Map

Accidentand

Emergency

Community Hospitals

AssessmentUnit(s)

Permanent place of residence

IntermediateCare

(services delivered in the patient’s home)

Death

Hospital

SpecialistWard

GP

Ambulance

Emergency Demand

Comment?

Emergency Admissions

Comment?

Relationship between flow in, A&E performance and deaths and emergency admissions

Comments?

Adult Non elective Rami(Rate Adjusted Mortality Index) (excl paeds, obs & midwifery)compared to average for peer group

A&E breaches &Non elective deaths / dischargesby date of admission

Weekly Flow Cost Quality

Ap 07 to Ap – Jan 11

Infection controlPalliative Care excluded > %15-64 years

admissions


Closure of Community HospitalSept 2009

Agenda for change

RecruitOpen new wards Total Pay costs

(elective and non elective)

High Level System Map

Accidentand

Emergency

Community Hospitals

AssessmentUnit(s)


IntermediateCare


Death

Hospital

SpecialistWard

GP

Ambulance

Closed 40 beds

Sept 2009

Continuing Health Care funding process changed

Oct 2009

Lesson for Boards:

Poor A&E performance is due to poor flow OUT– Constraints are under our control

Lesson for Performance Management

• Plot the dots!– Trend lines should be removed from Excel

– Statistical Process Control• Reveals the voice of the process

What did we learn?

• Plot the weekly emergency admissions by age group:• 0 to 15• 16 to 64• 65 to 79• 80 and plus

• Plot Patients-in-Progress (work-in-progress):– very sensitive to changes in demand x LOS:

• A&E performance (breaches)• Midnight bed occupancy

– See later

Correlates with the high level patient flows

Emergency admissions 80 years +

Confirms that poor flow is NOT due to increased admissions of patients > 80 years

High Level Emergency System Map

Accidentand

Emergency

Community Hospitals

AssessmentUnit(s)


IntermediateCare


Death

Hospital

SpecialistWard

GP

Ambulance

(0 to15) 16 to 64 65 to 79 80 and plus years

Warwick

Sheffield: GSM

GSM: How Many Bed Nights Do They Stay?

Pareto of Bed Nights for Home to Home Patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 6

12

18

24

30

36

42

48

54

60

66

72

78

84

90

96

10

2

10

8

11

4

12

0

12

6

13

2

13

8

14

4

15

0

15

6

16

4

17

5

18

9

20

5

26

3

Bed Nights

Cu

m F

req

Day to day Admissions Discharge mismatch

NEL Admission Discharge mismatch

01020304050607080

date

nu

mb

er

of

NE

L p

ati

en

ts

ad

mtt

ed

an

d d

ich

arg

ed

Total NEL admissions (NEL+ NEL other)

Total NEL discharges (NEL+ NEL other)

Elective Admission Discharge mismatch

01020304050607080

01/1

2/20

07

08/1

2/20

07

15/1

2/20

07

22/1

2/20

07

29/1

2/20

07

05/0

1/20

08

12/0

1/20

08

19/0

1/20

08

26/0

1/20

08

date

Nu

bm

er o

f el

ecti

ve p

atie

nts

ad

mit

ted

an

d d

isch

arg

ed

EL admissions

EL discharges

1. Reduce dailyvariation in discharges

2. Smooth Variation inPLANNEDElectiveAdmissions

0

50

100

150

200

250

300

350

400

450

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Time of Arrival into A&E Time of Departure out of A&E to Main Hospital

In-day mismatch between Emergency admissions and Specialist capacity

X junior staff

+Y

specialist consultants?

Patients admitted when capacity is not available

Assessment units are storage units to hold the patients until the specialist capacity is available the following day

Minimal capacity

Minimal capacity

12.0000.00 23.5906.00 18.00

When is the Specialist Capacity available?

Assessment Process at April 2009

History & examination& initial treatment

TriageRequestsTest & imaging

Perform tests& imaging

Senior ReviewPlan definitive treatment

History & examination

Transfer to Assessment Unit

4 hours.

NursingObs’

Senior review

ArriveAt A&E

NursingObs

Up to 12 hours overnightUp to 24 hours post arrival at hospital

A&E Assessment Unit


?

= value

What do we need to do instead?

0

50

100

150

200

250

300

350

400

450

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Time of Arrival into A&E Time of Departure out of A&E to Main Hospital

0

50

100

150

200

250

300

350

400

450

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Time of Arrival into A&E Time of Departure out of A&E to Main HospitalTime of Arrival into A&E Time of Departure out of A&E to Main Hospital

Specialists availableSeeing patients on wards

Discharging patientsAdmitting patients

Minimal capacity

12.0000.00 23.5906.00 18.00

The specialty capacity needs to be available:

08:00 21:00

Pull patients forward into the working day:• Stop making them wait 3:59 minutes…..• Stop duplication

Right decisionsOn time Every timeIn full

‘Future’ Assessment Process(Now current as at April 2012)

History & examination& initial treatment

Plan for diagnosis

RequestsTest & imaging


Senior specialist ReviewPlan definitive treatment

NursingObs’

ArriveAt A&E

2 hours

Transfer to Appropriate specialist areaincluding homewith PT/OT /SShome assessment at home

1 hour

Safe ambulatory care process now possible

Demand: numbers by day

All admissions from A&E by hour Mondays May to Oct 08

0

1

2

3

4

5

6

7

8

00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Hour of arrival

Ad

mis

sio

n

Max

Min

Avg

Av + 1 SD

Av +2 SD

What is the rate of production required?

Reduce dailyvariation in discharges

Medical Emergencies Arrival Time08:0008:1508:3008:4509:0009:1509:3009:4510:0010:1510:3010:4511:0011:1511:3011:4512:0012:1512:3012:45

All Emergencies Arrival Time08:0008:1008:2008:3008:4008:5009:0009:1009:2009:3009:4009:5010:0010:1010:2010:3010:4010:5011:0011:1011:2011:3011:40

Junior Doc Nurse X-ray Consultant doc

Planning Capacity of the workforce

4admissions/hr.

6admissions/hr.

Improving Flow (front end)

• Pooled junior docs– A&E, MAU and specialty on call– Staggered start times on A&E/MAU

= Increased availability from 08:00 to 10:00

• MAU consultants continuous flow• Speciality take every day: admissions• Heartbeat system for tracking patients

• Wards– Consultant ward round every day: discharges

Functional departments

Board

Flow


Support functions





Board


A&E

Transport

GP GP

Ambulance


Do this hour’s work this hour:

• Emergency Blood turnaround:– Bottleneck for emergency samples = centrifuges

Change: • Now a centrifuge starts every 3 minutes whether full or not

• IP blood monitoring on wards– Bottleneck: Phlebotomists & transport to lab

Change:• Porters running between phleb’s and lab• Steady flow of samples into lab• all results back by 10:30 a.m. for ward rounds

1 year later

• Warwick

• Focus on:– A&E, – Assessment units and wards– Diagnostics– Ward rounds– TTOs

Comments?

Infection control Palliative Care excluded

Agenda for change RecruitOpen new wards


Close CommunityHsp Sept 09

Acquire Community services

Dec 2010: flow improvements start

Reduction in death rate

Increased %16 to 64 years

Flow doesn’trecover from Sept 2009bed + staffclosures

Nobody addressedthe CHC admin delays causing the long LOS

Organisationchange disrupted the Admin flow even more

1 Year later

• Sheffield

Geriatric and stroke medicine– Focus on reducing the admin constraints (policies)– Check List and CHC assessment process

• 42 page document• 18 man hours of work• Min time (LOS) = 30 days+

– Home assessment at home on day of discharge• Referral to Social Services by physio to social services• SS package in place within 48 hours (Upper process limit)

– Home of choice:• out to residential home, CHC afterwards

Home of choice

Daily

Weekly

Lessons for executive support services

Board

Flow


Support functions





Board

DH, SHA, Monitor, Health Commission etc..

A&E

Transport

GP GP

Ambulance


Lessons for executive support services

• HR: – Systems thinking and improvement science for A4C 8 & above– Match staff capacity to patient demand: 7/7, 365– Heads of functions = responsibility for end-to-end process

Focus is on Flow,

WIP incurred accountable to the Dpt. concerned.

• IT – Information in real time– Time series data

• Estates:– Reduce transport and motion– Co-location of process resources

• Supplies – Just-in-time

Finance

Pareto analysis of the pay costs in one Trust for one month by employee.

50% of cost

20% of staff

Role of senior managers is toimprove process flow through the most expensive value adding staff =clinicians

Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6

Change the Finance Paradigm

Economies of Scale Economies of Flow

£5/hr

£1/hr

£2/hr

£1/hr

£1/hr £2

/hr

Dpt 1 Dpt 2 Dpt 3 Dpt 4 Dpt 5 Dpt 6

Activity x PbRincome

DemandPatients /hr

CapacityPatients/hr

Nu,ber of Patients treated successfullyLand lives ‘saved’

Drives Dpt manager to do more activity at less costAcquires ‘new business’ But what happens to flow?

Department Cost Activity

= unit cost= waste

So focus is on improving value delivered and incomeThis depends on moving resources to support the constraint

constraint

The constraint should be the most expensive resourcein the process = in Dpt 2. How can we optimise productivity through the most expensive resource?

Finance

• John Darlington’s paper• http://www.leanuk.org/downloads/LS_2010/paper_lean_bu

siness_case.pdf

http://www.leanuk.org/downloads/LS_2010/paper_lean_business_case.pdf



How to make changes happen

HistoryExamination Assessment30 minutes

Nil by mouth 4 hours

Fullblood Count5 minutes

Endoscopy&Breath test30 minutes

Transfuse8 hours

Discussion with cardiac centreRe stent15 minutes

Cross match40 mins

Discharge With PlanAnd Rx15 minutes

82% of time and resource wasted

Poor quality experience and outcomeFrom a Poor Quality System

Value adding

Non Value adding

34 hours

8 days x 24 hours18% of time value adding=

CheckFBC 5 minutes

Rest & dehydrate for 20 hours

Get Everyone on Board

Patient’s experience of waste

The Doctors can lead the change…..

• Very complex system:– Like a human body!

• Understand– Anatomy – Physiology (flows)– Plot the dots: BP, temp, pulse, resp’s ….– Diagnosis– Treatment (releave the constraints)– Look for changes in the pattern of variation (SPC)

Get the Managers on Board

• Top Down Command and Control is impossible: – Not possible for one person to understand whole end-

to-end process or System.

• Facilitate Big Room Meetings– Get the everyone in a room – Listening to each other– Conversations based on facts: – Study, Adjust, Plan, Do, – Monthly and Weekly reviews

Big Room Process

Summary

• Quality is a System property• Track patient flow (WIP), death rate and cost over time.

– Increasing cost doesn’t always improve flow– Reducing cost can have grave consequences

• Improve processes to reduce delays and inventory (WIP)– Match staff capacity to patient demand– Do this hour’s work this hour

• Shift from:– Unit Costing: Dpt cost/activity– to Flow Accounting: throughput at constraint/total process cost– The constraints are policies or availability of staff, not beds.

What have we learned ?

• Nuggets

• Niggles

• Nice-if

• NoNos

Parallel Session 3.2 Innovations in Acute Flow and Capacity Management

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Transcript of Parallel Session 3.2 Innovations in Acute Flow and Capacity Management