Squaring the circle of healthcare supplies.

PURPOSE: The purpose of this paper is to use a systems lens to assess the comparative performance of healthcare supply chains and provide guidance for their improvement. DESIGN/METHODOLOGY/APPROACH: A well-established and rigorous multi-method audit methodology, based on the uncertainty circle model, yields an objective assessment of value stream performance in eight Australasian public sector hospitals. Cause-effect analysis identifies the major barriers to achieving smooth, seamless flows. Potentially high-leverage remedial actions identified using systems thinking are examined with the aid of an exemplar case. FINDINGS: The majority of the healthcare value streams studied are underperforming compared with those in the European automotive industry. Every public hospital appears to be caught in the grip of vicious circles of system uncertainty, in large part being caused by problems of their own making. The single exception is making good progress towards seamless functional integration, which has been achieved by elevating supply chain management to a core competence; having a clearly articulated supply chain vision; adopting a systems approach; and, managing supplies with accurate information. RESEARCH LIMITATIONS/IMPLICATIONS: The small number of cases limits the generalisability of the findings at this time. PRACTICAL IMPLICATIONS: Hospital supply chain managers endeavouring to achieve smooth and seamless supply flows should attempt to elevate the status of supplies management within their organisation to that of a core competence, and should use accurate information to manage their value streams holistically as a set of interwoven processes. A four-level prism model is proposed as a useful framework for thus improving healthcare supply delivery systems. ORIGINALITY/VALUE: Material flow concepts originally developed to provide objective assessments of value stream performance in commercial settings are adapted for use in a healthcare setting. The ability to identify exemplar organisations via a context-free uncertainty measure, and to use systems thinking to identify high-leverage solutions, supports the transfer of appropriate best practices even between organisations in dissimilar business and economic settings.

Frank Gilbreth and health care delivery method study driven learning.

PURPOSE: The purpose of this article is to look at method study, as devised by the Gilbreths at the beginning of the twentieth century, which found early application in hospital quality assurance and surgical "best practice". It has since become a core activity in all modern methods, as applied to healthcare delivery improvement programmes. DESIGN/METHODOLOGY/APPROACH: The article traces the origin of what is now currently and variously called "business process re-engineering", "business process improvement" and "lean healthcare" etc., by different management gurus back to the century-old pioneering work of Frank Gilbreth. The outcome is a consistent framework involving "width", "length" and "depth" dimensions within which healthcare delivery systems can be analysed, designed and successfully implemented to achieve better and more consistent performance. FINDINGS: Healthcare method (saving time plus saving motion) study is best practised as co-joint action learning activity "owned" by all "players" involved in the re-engineering process. However, although process mapping is a key step forward, in itself it is no guarantee of effective re-engineering. It is not even the beginning of the end of the change challenge, although it should be the end of the beginning. What is needed is innovative exploitation of method study within a healthcare organisational learning culture accelerated via the Gilbreth Knowledge Flywheel. RESEARCH LIMITATIONS/IMPLICATIONS: It is shown that effective healthcare delivery pipeline improvement is anchored into a team approach involving all "players" in the system especially physicians. A comprehensive process study, constructive dialogue, proper and highly professional re-engineering plus managed implementation are essential components. Experience suggests "learning" is thereby achieved via "natural groups" actively involved in healthcare processes. ORIGINALITY/VALUE: The article provides a proven method for exploiting Gilbreths' outputs and their many successors in enabling more productive evidence-based healthcare delivery as summarised in the "learn-do-learn-do" feedback loop in the Gilbreth Knowledge Flywheel.

Enabling innovation in health-care delivery.

Achieving lasting performance improvement in health care is a demanding challenge. Service delivery processes are frequently fragmented with many symptoms of poor behaviour observable. Competing vested interests within the National Health Service (NHS) and experiences of muddled and muddied top-down government exhortation suggest the need for a balanced perspective in which the expectations of patients, staff, management and government can be considered, agreed and enabled. Our conclusion is that effective innovation is best achieved by establishing a 'Train-Do-Train-Do' cycle in which all 'players' in the system must be actively involved. The particular methodology of 'managing by projects' for effective bottom-up step-by-step innovation in NHS practice is described. It takes a holistic and systematic view of health-care delivery as a service business process to be optimized via a five-step procedure. The core tool element of this methodology is the multidiscipline natural-group task force used to execute the change process in an enterprise. When properly constituted, motivated and driven, it is very capable of transforming a 'mess' into an effective health-care delivery process.

Seamless healthcare delivery systems.

PURPOSE: Taking the physician sourced observation that "wasting time is always more expensive than saving it" leads naturally to the conclusion that effective and efficient patient-centred healthcare delivery systems are highly desirable targets for the National Health Service (NHS) and similar providers. But has "joined up healthcare" even been achieved, and if so, how? What procedures must be in place to maximise the chances of its occurrence? This paper aims to investigate these issues. DESIGN/METHODOLOGY/APPROACH: This paper answers these questions experientially via "Insider Action Research" projects plus careful critique of published case studies. FINDINGS: Recurring themes for effective improvement of healthcare delivery organisations emerge in the paper, as do identification of the inevitable barriers to change. ORIGINALITY/VALUE: The paper takes stock of NHS service developments in a broader theoretical light.

Re-engineering healthcare pipelnes: why trajectory selection is as important as process selection in enabling effective transfer of best practice.

PURPOSE: To demonstrate that effective re-engineering of healthcare pipelines requires selecting both the "best" process (how we shall do it in the future) and the best trajectory for change (how we get from here to there). DESIGN/METHODOLOGY/APPROACH: Exploitation of Braess' Paradox to identify strategic factors necessary to enable change in the re-engineering of NHS healthcare pipelines. FINDINGS: Route to maximising the chance of achieving effective change is displayed via a Johari Window. Each cell is then related to no change (despite significant investment); failure; or successful implementation. RESEARCH LIMITATIONS/IMPLICATIONS: The demonstrator pipeline is an NHS cataract repair supply chain. However, via the "Power of Analogy" concept the NHS scenario is readily related to a substantial number of industrial case studies. PRACTICAL IMPLICATIONS: The need to understand both process and trajectory is the key to effective re-engineering of pipelines. All "actors" in re-engineering programmes should acquire this knowledge and benefit from the new way of doing things. ORIGINALITY/VALUE: Formalises the strategic route to enabling healthcare delivery "best practice".

Viewing Kaiser Permanente via the logistician lens.

PURPOSE: The aim of this paper is to undertake a holistic comparison between NHS and Kaiser Permanente (KP) healthcare delivery systems. DESIGN/METHODOLOGY/APPROACH: The paper reviews in detail the many papers and communications published on KP via the "logistics lens" which is focussed on smooth patient flow from onset of problem to completion of treatment. FINDINGS: The paper finds that healthcare "best practice" is readily related to conventional supply chain performance metrics and engineering change model attributes. Much of the apparent success of KP is due to cultural and organisational factors. A noteworthy example deserving wide dissemination and application is in the effectiveness of interfaces between clinicians and managers. RESEARCH LIMITATIONS/IMPLICATIONS: This review exposes the need for the NHS to be driven by end-to-end processing times rather than the present salami principle of separating in-patient, out-patient and other queues into neat statistics, which can be meaningless to an individual patient. PRACTICAL IMPLICATIONS: Introduces clinicians and healthcare professionals to a range of tools and techniques for engineering "best practice". This method is well understood and proven in other areas of application. Particular aspects of the KP study are thus confirmatory of what is actually happening in small pockets of the NHS. ORIGINALITY/VALUE: The paper provides a new perspective on the performance of healthcare supply chains. New knowledge and deeper understanding of the mechanisms of success emerge from a study adopting a different viewpoint.