Part 3 of Reducing costs and improving quality in the NHS!

Health­care lead­ers with this new per­spec­tive on per­for­mance work smarter, rather than harder. There are a num­ber of high impact ways of doing this. The first aspect of work­ing smarter is to address the bot­tle­necks that are a con­stant char­ac­ter­is­tic of tra­di­tional health­care processes. We should actively seek out bot­tle­necks and address the fac­tors that cause them.

A bot­tle­neck is the stage in a patient process under the most pres­sure. It cre­ates queues, and slows down the whole process. For exam­ple, the bot­tle­neck in a hos­pi­tal set­ting might be spe­cific diag­nos­tic tests. Patients might be in hos­pi­tal beds wait­ing for diag­nos­tic test and test results. Speed­ing up the rate of tests in these cir­cum­stances is likely to speed up the whole patient process.

The quest to improve health­care per­for­mance requires us to sys­tem­at­i­cally iden­tify and then erad­i­cate bot­tle­necks in patient processes across the whole health­care sys­tem. Evi­dence sug­gests that by doing so, we can reduce organ­i­sa­tional com­plex­ity, and elim­i­nate ‘has­sle’ fac­tors for patients and staff. We need to sig­nif­i­cantly reduce bot­tle­necks to achieve the 18 week elec­tive wait­ing tar­get. Fewer bot­tle­necks also typ­i­cally mean lower costs.

The sec­ond aspect of work­ing smarter is to under­stand patients flow and recog­nise the impor­tance of address­ing vari­a­tion in patient flow. Flow means mov­ing patients through the sys­tem in a timely and effi­cient man­ner so that every patient gets the right care from the right staff, with the right infor­ma­tion at the right point in time.

We can never remove all the vari­a­tion from a patient process. Nat­ural vari­a­tion is an inevitable char­ac­ter­is­tic of any health­care sys­tem. Sources of nat­ural vari­a­tion include dif­fer­ences in the symp­toms and dis­eases that emer­gency patients arrive and socio-economic or demo­graphic dif­fer­ences among patients. We need to take steps to under­stand and plan for nat­ural variation.

By con­trast, arti­fi­cial vari­a­tion is cre­ated by the way the sys­tem is man­aged. Sources of arti­fi­cial vari­a­tion include:

• The way we sched­ule appoint­ments and elec­tive admissions
• The work­ing hours of staff
• How staff study leave and staff vaca­tions are planned
• The avail­abil­ity of clin­i­cal equipment

Arti­fi­cial vari­a­tion has a much more sig­nif­i­cant impact on patient flow than nat­ural vari­a­tion. Arti­fi­cial vari­a­tion is usu­ally dri­ven by the per­sonal pref­er­ences and pri­or­i­ties of staff, rather than actual demand for a ser­vice; for instance a sur­geon want­ing to oper­ate on a Mon­day morn­ing rather than a Fri­day afternoon.

Arti­fi­cial vari­a­tion is the enemy of smooth patient flow through the sys­tem. It cre­ates peaks and troughs in patient demand and in the capac­ity of the health­care sys­tem to meet that demand. As a result, it is the num­ber one cause of waits and delays in the sys­tem. Arti­fi­cial vari­a­tion can­not be man­aged like nat­ural vari­a­tion. Steps should be taken to elim­i­nate arti­fi­cial variation.

In order to elim­i­nate arti­fi­cial vari­a­tion, steps should be taken to mea­sure demand and capac­ity and match them con­tin­u­ously on a daily basis. Demand can be defined as the num­ber of patients with the require­ment for the ser­vice being referred to (or pre­sent­ing them­selves for) the ser­vice on an hourly, daily, monthly or annual basis. In order to under­stand demand, to min­imise vari­a­tion in the sys­tem and ensure smooth process flow, we need to know who these patients are and what their needs are.

We need to match our capac­ity (peo­ple, build­ings and equip­ment) to this demand. Yet many health­care organ­i­sa­tions do not actu­ally mea­sure demand. They mea­sure activ­ity (the work that their clin­i­cal teams actu­ally carry out). Activ­ity is a very poor basis for plan­ning capac­ity. Plan­ning on the basis of activ­ity rather than patient demand increases the poten­tial for arti­fi­cial vari­abil­ity in the sys­tem. As a result, waits get longer and costs get higher.

Part 4 to follow: Patient seg­men­ta­tion

Writ­ten by Helen Bevan  (Direc­tor of Ser­vice Trans­for­ma­tion) and Micheal Caw­ley (Direc­tor of Finance and Busi­ness Ser­vices at the NHS Insti­tute for Inno­va­tion and Improvement).

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