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Managing Variation, Understanding the Effects of Carve-out, Scheduling and Flow Managing Variation, Understanding the Effects of Carve-out, Scheduling and Flow

How do we manage variation in demand? • Delay • Forced booking • Carved How do we manage variation in demand? • Delay • Forced booking • Carved out capacity

Carve-out can be… 2 week wait Urgent Soon Routine Urgent follow-up Routine follow-up Secretary Carve-out can be… 2 week wait Urgent Soon Routine Urgent follow-up Routine follow-up Secretary Post-op Number of appointment types Huge Number of doctors Thousands of combinations It is impossible to balance the queues

Flexi-sig urgent soon routine OGD ERCP urgent soon routine Number of appointment types Ra Flexi-sig urgent soon routine OGD ERCP urgent soon routine Number of appointment types Ra dio log ist n 1 2 3 4 5 ys x x x x x x x x x soon routine x x Colonoscopy urgent ici a 1 on 2 3 4 Ph rge Su The size of the carve out Number of specialists x x x x x x x x x 73 queues

Queue type A Queue type B Server Server Queue type A Queue type B Server Server

Is all carve-out bad? • Capacity for urgent cases (prioritisation of patients) • Subspecialisation Is all carve-out bad? • Capacity for urgent cases (prioritisation of patients) • Subspecialisation • The issue is not to eliminate all carve-out, but rather to eliminate unnecessary carve-out and reduce the impact of carve-out we can’t eliminate

Terms Carve-out When the flow of one group of patients is improved at one Terms Carve-out When the flow of one group of patients is improved at one bottleneck at the expense of another group of patients Streaming or segmentation Separation of the process of care along the whole pathway for one group of patients to improve overall flow but not at the expense of other groups of patients

Analogy of segmentation and flow: traffic flow on motorway Slow lane 50 mph Middle Analogy of segmentation and flow: traffic flow on motorway Slow lane 50 mph Middle lane 70 mph Fast lane 90 mph All vehicles keep to same speed in allocated lane and all progress according to their need

What happens when lorry moves into middle lane at 55 mph? Slow lane 50 What happens when lorry moves into middle lane at 55 mph? Slow lane 50 mph Middle lane 70 mph Fast lane 90 mph • backlog of traffic • flow rates compromised • few needs met • actual consequences are not seen at point of bottleneck

When is it carve-out? • When ring-fencing resources for one group reduces resource available When is it carve-out? • When ring-fencing resources for one group reduces resource available for another group • How can we tell whether the problem is carveout or capacity?

Demand exceeds capacity If Demand > Numbers waiting will go up Activity or Capacity Demand exceeds capacity If Demand > Numbers waiting will go up Activity or Capacity Waiting times will go up

Carve out and churn = If Demand Number waiting is constant over time Activity Carve out and churn = If Demand Number waiting is constant over time Activity urgent routine But waiting times may not be “Skimming off the froth”

Variation and carve-out • Variation helps cause the waiting list • Carve out makes Variation and carve-out • Variation helps cause the waiting list • Carve out makes it worse • So what are we to do?

Match capacity and demand! • Set the maximum waiting time to the time the Match capacity and demand! • Set the maximum waiting time to the time the most urgent referral can afford to wait – Do today’s work today – Do this week’s work this week – Do this month’s work this month

What do we want to achieve? • Maximise Throughput By keeping every • Treat What do we want to achieve? • Maximise Throughput By keeping every • Treat the maximum number of patients with the machine and person minimum amount of waiting working flat out Wrong • How? Utilisation = efficiency Sweat the assets!

Flow • We need to optimise the whole process - not each individual step Flow • We need to optimise the whole process - not each individual step • Don’t maximise utilisation, maximise throughput • Manage the flow

How long does a scan take? • Multiple queues • Multiple slot types » How long does a scan take? • Multiple queues • Multiple slot types » » arthrogram thorax with contrast spine thorax • Eliminate the carve-out

Build new CT templates Prepare patient Scan patient Get off scanner Report Films Type Build new CT templates Prepare patient Scan patient Get off scanner Report Films Type Report 20 minutes - “Quickie” Prepare patient Scan patient Contrast 40 minutes - “Longie” Get off scanner Report Films Type Report

Monitor progress Monitor progress

Matrix Allocation: Step 1 Draw a matrix Condition 1 Condition 2 Condition 3 Condition Matrix Allocation: Step 1 Draw a matrix Condition 1 Condition 2 Condition 3 Condition 4 Condition 5 Consultant FF Consultant EE Consultant DD Consultant CC Consultant BB Consultant AA Condition 6

Step 2 Fill in the matrix x Condition 4 Consultant FF Consultant EE Condition Step 2 Fill in the matrix x Condition 4 Consultant FF Consultant EE Condition 6 x x x x x Consultant AA Condition 5 x x x x Consultant DD Condition 3 Consultant CC Condition 2 x Consultant BB Condition 1 Ensure all conditions have at least one consultant

Consultant FF Consultant EE Consultant DD Consultant CC Consultant BB Consultant AA Step 3 Consultant FF Consultant EE Consultant DD Consultant CC Consultant BB Consultant AA Step 3 Establish clinical care groups Condition 1 x x Condition 2 x x x Condition 3 ccg 1 x x ccg 2 Condition 4 x x Condition 5 x x x Condition 6 x x x

Consultant FF Consultant EE Consultant DD Consultant CC Consultant BB Consultant AA Patient with Consultant FF Consultant EE Consultant DD Consultant CC Consultant BB Consultant AA Patient with condition 4 Step 3 Allocate patients Clinical care group 4

40 35 30 25 20 15 10 5 0 70 Ophthalmology Outpatient Waiting List 40 35 30 25 20 15 10 5 0 70 Ophthalmology Outpatient Waiting List vs List for patients booked in turn 60 50 Actual Outpatient Waiting List 40 30 20 10 0 44 42 40 38 36 34 32 30 28 26 24 22 20 18 16 14 12 10 Wait (weeks) 8 6 4 2 0 Number Booked in Turn

Scheduling You cannot schedule your way out of a capacity problem. . . Scheduling You cannot schedule your way out of a capacity problem. . .

What doesn’t scheduling do? • Solve problems of a mismatch of capacity and demand What doesn’t scheduling do? • Solve problems of a mismatch of capacity and demand • Deal with unusual events

Define capacity and demand: Demand: 200 patients per month Capacity: 180 patients per month Define capacity and demand: Demand: 200 patients per month Capacity: 180 patients per month Backlog: 350 patients Activity: 160 patients per month Scheduling will not resolve this problem

The solutions: • Increase Capacity to match Demand • Decrease Demand to match Capacity The solutions: • Increase Capacity to match Demand • Decrease Demand to match Capacity • There are no other options!

Define capacity and demand: Demand: 200 patients per month Capacity: 240 patients per month Define capacity and demand: Demand: 200 patients per month Capacity: 240 patients per month Backlog: 350 patients Activity: 160 patients per month But it might solve this one. . .

An example of scheduling the bottleneck Flexi-sigmoidoscopy Prepare bowel Prepare patient Write notes Scope An example of scheduling the bottleneck Flexi-sigmoidoscopy Prepare bowel Prepare patient Write notes Scope Patient Nurse Endoscopist Recover balance Identify the - number of people - number of rooms - pieces of equipment available 2 loos for preparation 1 theatre for scoping 1 nurse for preparation 1 scoper for scoping and writing notes 4 recovery chairs for recovering balance

Line up the templates Wasted time Only 4 patients done Only 1 endoscopist, so Line up the templates Wasted time Only 4 patients done Only 1 endoscopist, so Only 2 loos, so cannot start 2 nd cannot start the patient till third patient until endoscopist free a loo is free! endoscopist can’t start till late What is the constraint? (defining capacity) What is the bottleneck? (current limit on activity)

What solutions can you suggest? • Add another endoscopy suite Add more toilets Get What solutions can you suggest? • Add another endoscopy suite Add more toilets Get patients to do the bowel prep at home J

Fix the loos and set new templates… 11 patients done in the same time! Fix the loos and set new templates… 11 patients done in the same time! Appointment times set so that the endoscopist starts on time the template Schedule around the constraint

What are the risks? • Some patients will not come fully prepared • They What are the risks? • Some patients will not come fully prepared • They will have to be rescheduled to another day or at the end of the clinic • Do not schedule to 100% utilisation of the scarcest resource • Do you want to fly in a plane that is scheduled to use 99% of the available fuel to get to its destination? • Remember that capacity is 80% of the fluctuation in demand

The road to ruin: Capacity plans and contracts based on average past activity Fail The road to ruin: Capacity plans and contracts based on average past activity Fail to account for variation in demand Fail to deliver required activity Income less than expected + Fail to account for variation in capacity Guarantee waiting times beyond emergency and elective targets Increased variations in capacity Reduces effective capacity Increase staff overtime & waiting list initiatives Increased costs Cost cutting initiatives

The road to financial health Capacity planning and contracts based on variation in demand The road to financial health Capacity planning and contracts based on variation in demand Required activity guaranteed No waiting beyond emergency or elective targets Income guaranteed Costs controlled Staff capacity to reduce variation in capacity increases productivity