Bottlenecks

Shifting current waiting times to 18 weeks requires a reduction in backlog of patients at every stage of the journey. Looking at and matching capacity and demand is a key approach to removing some of the visible and hidden backlogs along the patient pathway.

A bottleneck is usually caused by something - this is known as the constraint. The constraint is the part of the process which ultimately restricts the amount of work that can be done. By concentrating on the bottlenecks, you can accurately manage demand and capacity and therefore keep the flow of patients moving, which will in turn reduce overall waiting times.

Concentrate on the bottlenecks to reduce delays

You need to:

• Look very carefully at the process map (a guide to mapping patient journeys - process mapping, a conventional model and identify stages in the patient journey where patients have to queue or are put on a waiting list - this is a bottleneck
• Map that part of the process in more detail to make sure you really understand what is going on. Map to the level of what one person does, in one place, with one piece of equipment, at one time
• Look carefully for the true constraint. This is often a lack of availability of a specific skill or piece of equipment. Queues tend to occur before the bottleneck in the patient journey, and clear after the patient has gone past the stage with the constraint
• Measure at the bottleneck to really understand the capacity and demand. These guides will help you: quick introduction and comprehensive guide
• Begin to test and implement the relevant change ideas as a result of what the measurement shows you
• Keep asking ‘why?’ (five whys) to try to discover the real reason for the delay. For example, if your starting point is ‘the clinic always overruns and patients have to wait for a long time’, ask why at least five times. Possible responses might be that the consultant doesn’t have time to see all their patients in clinic as they have to see everyone who attends, including first visit assessments and follow-up patients
• Create templates of the processes (process templates), begin to schedule these templates and watch the whole process improve
• Keep a look out for other bottlenecks. In the whole patient journey there is likely to be at least one bottleneck

 

Different types of bottlenecks

Bottlenecks are the parts of the healthcare system with the smallest capacity relative to the demand. There are two different types of bottlenecks: process bottlenecks and functional bottlenecks.

 

1. Process bottlenecks are the stage in a process that takes the longest time to complete. Process bottlenecks are often referred to as the ‘rate limiting step or task’ in a process.

 

 

In the example above, activity 3 is the process bottleneck as it takes the longest time. This may be the consultant seeing the patient in outpatients.

 

2. Functional bottlenecks are caused by services that have to cope with demand from several sources. Radiology, pathology, radiotherapy, and physiotherapy are often functional bottlenecks in healthcare processes. Functional bottlenecks cause waits and delays for patients because:

• One process, such as ENT surgery, might share a function, such as imaging with other processes, e.g. orthopaedic surgery, and medicine
• A surgeon may be called to theatre when he is also needed in outpatients

This type of bottleneck causes a disruption to the flow of all patient processes. Functional bottlenecks act like a set of traffic lights, stopping the flow of patients in one process while allowing the patients in another process to flow unheeded. Where you have a bottleneck, there is usually a queue i.e. a delay that the patient will experience.

 

Methods for reducing the effect of bottlenecks

• Ensure that the bottleneck has no idle time, for example, have a list of stand-by patients who can be called at short notice in the event of idle capacity
• Put inspection or checking tasks in front of the bottleneck (e.g. if the bottleneck is the doctor in clinic, check that all test results are available at the clinic)
• Don't allow the room or clinical area to be the bottleneck
• Distribute the work amongst the clinical team so that everyone works to their highest level of skill and expertise, for example take administration away from rehabilitation nurses and give it to appropriate clerical staff
• If experts are the bottleneck they should only be doing work for which an expert is needed e.g. the development of nurse-initiated transfer from critical care.
• Separate responsibilities for clinical care and paper flow
• To increase the capacity of the bottleneck, give some of the work to non-bottleneck areas, even if it is less efficient for these areas
• Having improved the situation at one bottleneck, others may emerge as rate-limiting steps in the patient journey. Bottleneck management is, therefore, a process of continual improvement

The following links may also be useful:

 

Process Templates

Process Mapping

Theory of Constraints.

Five Whys

SPC

Understanding Variation

Discharge Planning

Keep Things Moving: see and treat patients in order

Booking and Choice

Process templates

Waiting List Management

Quick introduction to Demand and Capacity

The NHS Institute for Innovation and Improvement’s website holds the updated Improvement Leaders’ Guides, including ‘Matching Capacity and Demand - Process and Systems Thinking’.

Bottlenecks form part of demand and capacity theory, which originates from the theory of constraints.

This information was adapted from The NHS Institute for Innovation and Improvement’s Improvement Leaders’ Guides: ‘Matching Capacity and Demand - Process and Systems Thinking’.