What is it and how can it help me?
A template or a picture of what happens to one patient as they go through a process, measured in time. Using templates or pictures of patients' journeys through a process (ie the normal activity) can help you identify any constraint or rate limiting step within that process.
This enables you to schedule work more effectively: for example, booking patients at times to reduce their waiting. It also allows you to actively manage the constraint and maximise the efficiency of any process.
When does it work best?
Evidence suggests that this approach increases capacity within existing resources because it identifies and focuses on the rate limiting step in clinical settings such as endoscopy, chemotherapy, day surgery and radiotherapy. By focusing on the constraint, you can increase throughput and prevent mismatches in capacity and demand.
How to use it
Map out the processes around the procedure or work
Identify the start and end points of the procedure ie from the patient's arrival in the department, through to discharge. See below:
Agree how many key activities are undertaken, for example: patient clerking and consent; any pre-procedure preparation; getting the patient into the procedure room and positioned; carrying out the procedure; reporting findings; patient recovery; discharge.
Developing a template of your process
Follow a sample of patients (ten to 15) through each procedure, recording the time taken to complete each step. If you track ten patients, your grid might look like this:
One way to do this is to sort the patients in order (for example by clerk-in time). This gives you a result of two minutes.
Expanding looks like this:
The result of this for the whole pathway looks like this.
Allocate a colour to each step like this.
Line up the colour steps in sequence in blocks that are proportional to the time scale. Don't include waiting times. You can create the template in a spreadsheet, or by simply cutting and sticking coloured bits of paper together. Whichever way you choose, keep a consistent scale of the times along the top of the template.
This picture also shows the cumulative time used up in minutes at the start of each step.
The green box at the bottom, (type up report) shows a process that is running parallel to the patient pathway.
It is helpful to identify these steps separately as shown in this picture. Sometimes there can be a series of parallel steps taking place that can its own process template. One of the two series series of parallel steps will take longer than the other and dictate how many patients can be seen.
Now line up several templates so that patient waits are minimised.
Position real time (ie time in the day) along the top to work out the best time for patient appointments to start, optimum theatre usage and list composition.
Use the process template to schedule resources and staff for the number of procedures.
If you have different groups of patients in your clinic, you may wish to develop separate templates if their resource requirements vary, eg follow-up patients compared to new patients. However, you don't have to - you may find general templates easier and sufficient to reduce the complexity of what you are trying to plan.
Analysing and using the process template
Demand at the constraint:
Use the time required at the constraint and multiply this by the number of patients seen in a day - this is the activity at the constraint
Identify patterns of demand over time (daily, weekly, monthly) and by groups of patients
Use your booking system to identify slots that will meet demand
Timings for the other process stages give very useful information about the current approach to scheduling, in comparison to the capacity available.
Scheduling rules for different process templates:
Use the following rules to organise your schedule:
Order groups of patients that are highlighted as a variable in the constraint towards the end of the day
Arrange long templates first and then arrange smaller and shorter procedures around these
This exercise provides useful information in identifying key constraints in the process, related to available capacity. Availability of endoscopes, availability of recovery beds, equipment turn-around times and so on, can all impact on the time it takes to complete a procedure. Your future scheduling can take account of all constraints, eliminating their impact.
1. A real clinic schedule
How could you organise this better? Both patients and staff would benefit from improved scheduling.
2. Cancelled Operations
Operations were being cancelled due to a lack of beds, which was identified as the likely constraint.
A simple process template was developed just for bed use. As beds are ring-fenced for men and women, they have a separate template. The picture below shows how this looked for 15 patients who had planned admissions on the week beginning Sunday 15th February.
Each coloured block represents one day in bed. Blue boxes represent men and pink women as their beds are in separate wards (ie beds are not a shared resource for patients). Patients are discharged in the morning.
Process templates were used to map out the beds used.
In total, there were 64 patients admitted during this week. This spreadsheet was completed for all the patients. As each coloured box had a 1 in it, it was possible to add up the planned bed usage across the week.
These were then plotted in the following graph.
This graph showed that there was a peak in the demand for beds on a Thursday. In fact, the hospital needed four times the number of beds on a Thursday compared to a Sunday. More female beds were needed than male beds. It also took a while for bed demand to clear after admission.
Kate decided to build up this picture by adding two more week's worth of admissions. The result is shown in the graph below.
This demonstrates the variation in demand for planned beds in elective care. As beds had been identified as a constraint, further analysis was done and the following two strategies were recommended to alleviate the pressure:
Plan for discharge (reduce the demand / need for bed per admission)
Plan along bed utilisation rather than theatres
You should now be in a position to use the template to schedule your planned activity efficiently and effectively.
Managing clinic workload
If your focus is managing clinic workload, you can anticipate the best time for patients to start their appointment and have a good idea about what will happen if something unexpected occurs. Possible next steps build on capacity and demand, communication and more improvement work.
Build the template into your booking systems
Having involved administrative staff in the process mapping, you need to make sure that there is a simple system in place for booking different types of patients into the next available slot. Consider how many slots you need for each group daily and weekly. Colour code the slots by group making it easier for staff to book the right patient into the right appointment. This approach can be built into choose and book systems: the key is to make sure that each type of slot is easily recognisable.
Improve the impact
This approach works best if resources are being pooled for the non-specialist activity or the most common procedures. Process templates for individual consultants do improve their individual throughput but aren't necessarily the most profitable use of this tool.
Improving workflow of the clinic
If you are looking for continuous improvement, there are some other tools and techniques that you may find useful. For example, having simple visual cues so that everyone knows the patient has left the room and the next room is ready. Tools like and may also help to smooth the daily workflow of a clinic.
Strategies to protect the constraint
Tracking shifts in demand
Monitor referrals and follow-ups. How will you identify and respond to change?
This approach has its origins in the manufacturing industry where it was first used as a sensible way of scheduling work to take account of the resources required from start to finish. As an approach, experts rate its significance in the organisation of healthcare services so highly that they identified it as one of the ‘10 High Impact Changes'. It also links to capacity and demand analyses.
Acknowledgements / sources
The guidance about how to develop a process template originates from ‘Modernising Endoscopy Services: A Practical Guide to Redesign' NHS Modernisation Agency 2003.