Improving intra-day patient flow with single-piece flow principles
- Spencer Humphrys
- Jul 19, 2024
- 5 min read
In-hospital flow is returning to the priority list as health systems prepare for this Winter in earnest. We've worked in more than 80 hospitals and health systems in England, probably more if we thought about it longer. There are similarities in all the places we've been to, good and bad, in mental health, community hospitals, acutes, care at home, and so on. One universal goal is always to increase patient throughput. Clinical and operational teams want shorter lengths of stay, earlier discharges, and patients leaving when they no longer need care or support.
There are so many ways to improve patient flow we could write a book on the approaches and opportunities. But this blog focuses on single-piece flow. If you try any of this out, as a rule of thumb, try it in your best-performing unit with your most cohesive and forward-thinking team. They may be the pinnacle of your organisation, but we guarantee they can improve. Some of you might read that and disagree, but at one point, there was nothing better than a candle to light a room and no better phone than a Nokia. You're hopefully not that far back, but when delivering change, make it easy for yourself. Yes, there are probably more significant gains in other units or wards, but change is hard enough, and chances are that there are other things on the to-do list. Start small, get wins, build momentum and project evangelists, and then scale to the problematic areas with more significant opportunities.
One of the ways to make significant steps forward in any process is to adopt the principles of single-piece flow. Single-piece flow is a Lean concept, and unfortunately, one that isn't consistently used in health. Single-piece flow is where one 'thing' is worked on until completed before being passed on to the next stage individually rather than working in batches. If you have time, this 5-minute video is excellent:
The 'thing' being worked on can be anything: blood samples, paperwork, TTOs, referrals, or patients. The principle is the same.
Almost universally, when facing a complex problem, people don't spend enough time framing it. In our experience, this leads to the wrong problem being considered or alternative options not being fully explored. Not having the time to fully understand and frame the problem may be more accurate in health and social care, given the constant pressure and need to make rapid improvements.
An excellent example of this is 'improving flow'. But what does that mean, and what issue are we trying to solve? Often, 'flow' is used as a catchall for every element of inpatient flow. We think flow conversations should be broken down into intra-day and inter-day flow. In English, either improving the flow of a 24-hour period or improving the flow over consecutive days. Separating it this way, most 'flow' work focuses on the inter-day flow. Reducing occupancy, improving weekend discharges, etc., and ensuring intra-day flow are often missed. Frequently, hospitals and systems concentrate on resolving the issues in the complex few, those people with complex needs requiring a complicated discharge. These people consume most bed days (ideal for inter-day flow projects) but only equate to around 5% of discharges. So, when considering intra-day flow, we must focus on the other 95% of discharges. Both intra- and inter-day flow issues drive the UEC performance metrics. But, intra-day improvement may yield better and quicker results for some trusts. Anyone who has ever managed an A&E, a site team, or hospital flow knows that A&E attendances are predictable, as are admissions and discharges. The usual pattern is A&E attendances rise from around 09:00, peaking at about 13:00 before a short drop off to the second peak later in the afternoon. Patients needing admission also grow through the day, generally in line but a few hours after the attendance pattern described above. But discharges don't match. They often peak between 16:00 and 18:00. With an A&E filling up with patients waiting for admission, initial assessments and treatments will be delayed because of a lack of physical cubicle space. Generally, longer waits to be seen and missed or delayed treatments lead to increasing admission rates, increased harm, and longer length of stay for admissions. A vicious cycle. But what would happen if the discharge curve was shifted earlier by two, three or four hours? A&E would be less crowded, there would be space to see patients (bringing down the wait to be seen), and decisions could made earlier in the day when the health and care system was still in 'normal' working hours. How do you shift the discharge curve of 200 or 300 discharges? It's not by focusing on 15-20 complex discharges, that's for sure.
So, how could single-piece flow work and make an impact?
Imagine this. It's 09:00 on a full acute medical unit. The MDT has just finished the board round, with six patients identified for discharge (we'll call this 'start'). The medical team first sees the sick patients and then sees potential discharges around 10:00 (60 minutes after 'start'). The first patient is seen and can be discharged, and the MDT confirm that TTOs and a discharge letter are required. The team continued, completing the round at noon. A junior doctor was allocated to complete all the TTOs and discharge summaries. After being on a board and ward round for 3.5 hours, they pop to the loo and grab a drink before starting at 12:15. The TTO for the first patient was sent at 12:25 (205 minutes after 'start'). The TTO takes 1 hour to be processed, put together, checked and signed (13:25; 265 minutes after 'start'). However, the Pharmacy doesn't have a pod system, so they rely on a porter to collect and deliver the TTOs. When the first TTO was complete, the porter was already delivering TTOs. The TTO sits in the Pharmacy for 30 minutes until the porter returns (13:55; 295 minutes after 'start'). They gather the new TTOs, sign them out, and walk around the hospital to deliver the new batch. The TTOs get to AMU 15 minutes later (14:10; 310 minutes after 'start'). Luckily, the AMU is quiet, and all the jobs were complete, so as soon as the TTOs arrived, the patient was discharged (14:20; 320 minutes after 'start'). This is working in batches.
Now, let's imagine a single-piece flow process just for the ward round, with all processes taking the same processing time as above. The first patient is still seen at 10:00, and their MDT review is complete by 10:10. This time, the junior doctor completes the TTO at the bedside. By 10:20, the TTO gets to the Pharmacy instead of at 12:25. This patient was then discharged at 12:15, two hours earlier than the batch process, with no additional work. Single-piece flow doesn't create more work; it makes work move more smoothly and balances work for everyone.
There are always challenges in moving to single-piece flow. In the above example, these might be some issues:
The ward round may take a little longer
Additional staff might be needed to complete the TTOs in real-time
Training of the junior medical team might have to alter
Pharmacy staffing might not be sufficient to receive TTOs earlier
A deep operational understanding of the processes, impacts and unintended consequences is essential in all improvements to foresee, manage and mitigate these challenges. Moving to single-piece flow doesn't have to jump from batches of 20 to single items; start by just cutting your batch size in half. And as the new process works and things adapt, cut it in half again. Batching work always creates waiting. Sometimes, single-piece flow isn't practical (e.g. using 200 planes to fly people individually instead of one 737). But for these situations, reducing batch sizes and removing unnecessary waiting is still possible; you just need to understand your ideal batch size. The principles of single-piece flow apply to everything, from SDEC efficiency and system control centre activities to referrals and complex discharges.
But remember that single-piece flow is one improvement technique in a world of tools and techniques. Picking the right technique for the right problem that's most suited to your culture is crucial. If you want to know more about single-piece flow, adopting lean, or improving flow in your organisation, reach out for a chat.
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