A Practical Approach To Improving patient flow using The

Theory of Constraints

Oxford Radcliffe NHS Trust

Oxford Radcliffe Hospitals Trust

• The Trust has nearly 1,500 beds

• 400,000 people attended outpatients

• 112,000 patients were admitted

• 90,000 accident and emergency attendees

• 7,000 babies were delivered.

• Over 10,000 staff work in the organisation

What is The Theory of Constraints?

Eliyahu Goldratt first used in industry - Thinking ToolNot a set of solutionsFocus for ChangeWhole systems approachSimple common sense steps

TOC Process = 5 Steps

(Step 0 - Map the System)

Step 1 - Identify the Constraint

Step 2 - Get the most out of the constraint

Step 3 - Support the systems constraint

Step 4 - Elevate the systems constraint

Step 5 - Go back to step 1

Rate Limiting Step – Weakest Link

Referral OPD Waiting list

Pre –assessment

surgery OPD

100 60 50 25 12 60

Types Of Constraint

Find The rate limiting factor:

• Physical bottleneck – a capacity limited resource

• Thinking Constraint – ‘We’ve always done it like that’

• Policy Constraint – an organisational policy whether written or believed

Constraint V Bottleneck

• Bottleneck: Any resource whose capacity is less than the demand placed upon it.

• Constraint: Bottlenecks come and go. A constraint limits the whole systems performance over an extended period of time.

Benefits of Mapping

• Gain Agreement on what is ‘Whole System’

• Identify True Constraint

• Highlight queues & time span

• Identify other bottlenecks/issues

• Starting point for redesign

• Step 5 – Cause & effect

TOC as a Generic Tool

Principles may be applied to any whole System

• Gynaecology

• PND & Ultrasound

• MaxilloFacial/ Orthodontics

• Urology

• Finance

• Horton General Hospital

Case Study – Horton General

• District general hospital = 240beds

• 2000 –2001 Long Trolley Waits

• High Cancellation of electives due to”no beds available”.

Introduction Of TOC

• April 2001 – Capacity group formed

• April 2001 – TOC Workshop for key stakeholders

• May 2001 – System mapping and analysis

HGH – Identify the Constraint

A&E

Surgery

Medicine

Trauma& Ortho

Treatment

Waiting List

Discharge

Discharge+

Social CarePCT

5 Steps of TOC

Step 1 – Identify the constraint = Nursed beds

Step 2 –Get the most out of the constraint =

24hour stays, bed usage by A&E.

Location of Day case patients

Step 2 – Get the most out of the constraint!

• Not about working harder.• Constraint should only work on core role –

otherwise capacity wasted.• Nursed beds – most appropriate use of bed

stock & nursing activity• Starting point for analysis

Maximise Efficiency

Nursed beds

A&E

Waiting List

Inpatient orDay case

24 hour or less time as IP

PCT

Referrals into A&E

Information

Information

• 25% of admissions through A&E stayed 24 hours or less – of those:

- 25% non specific chest pain

- 18% self harm

• Minimal day case activity found in inpatient areas.• PCT – A&E used appropriately by GP’s

Information V Anecdote

• Many decisions about waiting times are based on anecdote not fact!

5 Steps

• Step 3 Support the constraint New ways to offload the constraint.

• Emergency transfer beds – existing area

• Discharge Lounge – Old children's ward

• Discharge ward

5 Steps of TOC

• Step 4 – Elevate the constraint

• Discharge Beds - increase in capacity

• New build for Emergency transfer Beds

• Step 5 – Go Back

Results so far….

• Trolley waits reduced

• Over 80% of patients are admitted within 4 hours of decision to admit in A&E

• Number of elective cancellations reduced.

Results

Horton > 12 hour waiters

0

5

10

15

20

25

30

May-01

J un-01

J ul-01 Aug-01

Sep-01

Oct-01

Nov-01

Dec-01

J an-02

Timeline

Nu

mb

er

of

Pat

ien

ts Horton >12 hourw aiters

Emergency Admissions

Surgical Cancellations

( no beds)

December 2000

582 18

December 2001

654 13

January 2001 599 50

January 2002 654 21

Discharge beds

020406080

100120140160180

Bed Days

Medicine Trauma &ortho

GenSurgery

Gynae

Specialty

Occupied bed days by Specialty (Discharge Unit)

December 2001

J an-02

Lessons Learnt

• More efficient to “pull” patients through the system than “push”

• Process mapping essential to understand the system

• Accurate, focused information is needed to diagnose problems and to measure success.

Summary

• Theory of Constraints – Common Sense approach to whole systems efficiency

• Promotes ownership of the problem by the staff delivering the service.

• Needs high level Sponsorship if it is to be effective.