Nathan Proudlove

Lessons for Lean in Healthcare from Using Six Sigma in the NHS

In the UK the National Health Service (NHS) has applied a number of quality improvement approaches from manufacturing, often in a piecemeal fashion; most notably Six Sigma and, more recently, Lean. This article reports on an evaluation of a programme used in the NHS to consider what can be learned about the application of such approaches—including what themes also apply to Lean, and its implementation, particularly in the healthcare context.

Can good bed management solve the overcrowding in accident and emergency departments

The NHS Plan1 makes the commitments that a patient’s total time in accident and emergency (A&E) will be no more than four hours. Many trusts are currently struggling to reduce four hour trolley waits (the time from the decision to admit (DTA) to leaving A&E). A recent survey conducted by the BMA and the British Association for Accident and Emergency Medicine2 suggests that official figures give an over-optimistic picture of the current pressures in A&E departments, and long patient waits are still common. The ability to move patients with a DTA out of A&E depends on the ability of the hospital to accommodate them (or to accommodate patients from the MAU, etc, to make room available). This movement is normally the responsibility of the bed management (BM) function, according to the National Audit Office (NAO),3 and this is the case in all trusts with which we are familiar. BM forms an important part of operational capacity planning and control, a wider activity concerned with the efficient use of resources. Outside the health context, the production/operations function of an organisation is concerned with activities such as scheduling and work flow to enable throughput to meet demand, and minimise work in progress and maximise resource utilisation. Despite the obvious analogies, very few acute hospitals have an operations management function. The objective of this paper is to demonstrate the part that operational capacity planning and control, in particular BM, plays, and could play, in improving service delivery. It starts by describing the typical function and structure of BM in acute hospitals, patterns of hospital activity, and their effects, particularly on A&E. Developments in operational capacity planning are then considered. These aim to improve planning and management of supply and demand, and moving towards and maintaining lower bed occupancy in medicine. …

OR and the challenge to improve the NHS: modelling for insight and improvement in in-patient flows

This paper considers efforts to improve in-patient flows, a particularly urgent issue in the National Health Service (NHS). The context is described and related to reasons why OR has been making relatively little contribution. The paper argues that large complex models may often be unnecessary and even get in the way of providing clear insight and guidance for problem owners. The importance of understanding the generic working of systems to lead to improvement, and the limitations of simply describing them, is stressed. It is demonstrated that some very simple models can be of significant practical value in understanding and managing complex systems, changing mindsets and driving collection and use of operationally valuable data. Recommendations for more effective engagement with the NHS are offered.

An exploratory study of bed management.

This paper analyses the role of bed managers and the processes involved in admission, stay, transfer and discharge of patients in the hospital setting. The paper seeks to begin a discussion of the difficulties entailed in the allocation of beds within the context of confined resources. This is achieved by: a review of the somewhat sparse literature on bed management and associated issues; the development of frameworks of analysis with regard to what bed managers do and the information used to support the bed management function; and an explication of results from fieldwork. This is followed by a discussion of the scope of responsibility and career role of the bed manager as well as the potential and problems of bed data. Contacts with others investigating this field and other trusts indicate that the situation in Greater Manchester may be typical of most areas.

Using operational information and information systems to improve in‐patient flow in hospitals

PURPOSE To consider how information and information systems can be used to support improving patient flow in acute hospitals (a key target for the National Health Service in England), and the potential role of the National Programme for Information Technology currently being developed. DESIGN/METHODOLOGY/APPROACH The literature plus past and present research, teaching and consulting experience with all levels of the National Health Service is drawn on to consider information provision and requirements. FINDINGS The National Programme for Information Technology specifies many features designed to support improving patient flows, though timescales for implementation are longer than those for the pledged flow improvements, and operational use of this type of information system has been problematic in the National Health Service. RESEARCH LIMITATIONS/IMPLICATIONS The work is limited to the National Health Service and information systems in use and planned for it. The National Health Service access targets, flow improvement initiatives and the National Programme for Information Technology apply primarily to England. PRACTICAL IMPLICATIONS Some bed/flow management information systems currently in use incorporate tools and capabilities in advance of what is outlined in the National Programme for Information Technology, and some rare cases of culture changes in information system use have been achieved. One should learn from these to inform development and implementation of National Programme systems. These existing information systems and approaches may also be useful to hospitals considering systems prior to implementation of the National Programme for Information Technology. ORIGINALITY/VALUE There has been very little consideration of the use of operational information and information systems for bed/flow management in the literature. Development and implementation of National Programme for Information Technology systems should build from an understanding of the practice and context of bed/flow management.

A statistical investigation of inventory shrinkage in a large retail chain

Abstract In a large retail chain, we used statistical regression to relate shrinkage to explanatory variables such as staffing, security, store layout and catchment-area demographics. There were large measurement errors in the retailers estimates of shrinkage, together with high correlations among the potential causal variables. These effects caused our models to give poor predictions of shrinkage for individual stores, but the models were highly statistically significant, which means that they can accurately forecast the average (and hence the aggregate) effects of policy changes affecting hundreds of stores. Factors associated with lower shrinkage included high turnover of stock, and high densities on the sales floor of staff, pay-points and customers. Our results suggest that crowding among staff and customers may be a more effective inhibitor of shrinkage than many traditional formal security precautions, such as CCTV and store detectives.

Towards fully-facilitated discrete event simulation modelling: Addressing the model coding stage

Abstract The literature suggests that increasing stakeholder engagement has a positive impact on projects using discrete-event simulation in healthcare. This suggests projects should strive to involve the stakeholders in as much of the project as possible, through facilitated workshops. A notable gap in stakeholder involvement is the model coding stage, in which a conceptual model is turned into a discrete-event simulation model running on a computer. This paper investigates how and under what circumstances model coding might also be conducted in facilitated workshops, in particular through the use of the Business Process Model and Notation (BPMN) modelling standard. This work arose from a series of modelling projects with two hospitals, one in Italy and the other in the UK. The paper describes how BPMN can contribute, with a case in which model coding was achieved in a facilitated workshop and a second in which it was not but which highlights further barriers to this in some contexts. These barriers arise from the detail necessary for requisite modelling regarding (i) the level of complexity of the model and (ii) challenges in data access and analysis to populate the model. The relationship between the technical capabilities of tools available and the impact of these barriers is also discussed. We believe this is the first time that discrete-event simulation model coding in a facilitated workshop in healthcare has been described, and we provide a clear view of the further barriers. To indicate when facilitated model coding is currently achievable, we suggest a contextual matrix.

A BPMN extension to support discrete-event simulation for healthcare applications: an explicit representation of queues, attributes and data-driven decision points

Stakeholder engagement in simulation projects is important, especially in healthcare where there is a plurality of stakeholder opinions, objectives and power. One promising approach for increasing engagement is facilitated modelling. Currently, the complexity of producing a simulation model means that the ‘model coding’ stage is performed without the involvement of stakeholders, interrupting the possibility of a fully facilitated project. Early work demonstrated that with currently available software tools we can represent a simple healthcare process using Business Process Model and Notation (BPMN) and generate a simulation model automatically. However, for more complex processes, BPMN currently has a number of limitations, namely the ability to represent queues and data-driven decision points. To address these limitations, we propose a conceptual design for an extension to BPMN (BPMN4SIM) using model-driven architecture. Application to an elderly emergency care pathway in a UK hospital shows that BPMN4SIM is able to represent a more complex business process.

Cracking the rankings Part (i): Understanding the Financial Times MBA rankings

League tables are of great interest to universities. This is particularly true for business schools, for which the Financial Times (FT) produces a suite of rankings of programme areas on a rolling annual cycle. Despite publication by the FT of most of the inputs and outlines of the methodologies, these are often little used by business school managers or researchers. This is the first of a pair of papers that show how the FTs data and methodology can be used to reconstruct the underlying calculations to a very high degree of fit. This can help business school managers understand strengths and weaknesses and thus inform strategic decisions. Researchers can also test hypotheses they advance or search for patterns more robustly. This article concentrates on the FTs programme area rankings, using the MBA rankings as the main example; the second paper turns to their more complex aggregate European Business Schools ranking.

‘Search Widely, Choose Wisely’: A Proposal for Linking Judgemental Decision‐Making and Creative Problem‐Solving Approaches

Brainstorming was pioneered by Alex Osborn as a technique to support idea generation in individual and team applications. The emphasis on divergence was moderated in subsequent technique systems, including the Parnes-Osborn approach and its derivatives. These systems place emphasis on both divergence and convergence, in one or more search/choice sequences. Nevertheless, an emphasis on divergence remained, both in training and practical application. Only more recently have the processes of converging attracted the attention of practitioners and researchers. In some contrast, there is a body of knowledge on judgmental decision-making which has focused on the convergent processes within individual and team problem-solving, while being less concerned with search procedures. A way of combining the two paradigms is suggested, illustrated by an example from a team applying such techniques in an exercise seeking to assess the creativity of organizations.