Improving patient flow: examining the application of lean management and theory of constraints across different healthcare settings

The importance of patient flow as a construct is clearly evident today in healthcare institutions and conferences, but, as with manufacturing, there needs to be a mechanism tailored to the instability of needs in this environment. This is reflected in the development of different manufacturing mechanisms, including Ford's physical flow lines, Ohno's Kanban control, and Goldratt's time buffer management (TBM), but little is known about the factors underpinning these distinctions and how they translate to the underlying healthcare environments. This research aimed to gain a deeper academic understanding of how established flow management mechanisms have been developed to meet the distinct conditions within the wider healthcare system, with specific reference to the origins of lean management (LM) and the theory of constraints (TOC). To accomplish this, a multi-case study approach was conducted, based on four healthcare organisations across three NHS Trusts in the UK. The cases incorporated acute and rehabilitative hospital care, social care, out-patient services, and GP-led community care and community mental health. Patient flow was improved and managed effectively in those cases where the flow mechanism was applied proactively to ensure that patients progress through each stage of the delivery system to minimise the length of stay (LOS) and target causes of flow disruption. This was evident in the TBM solutions witnessed, including the need to subordinate the flow focus to the planned discharge date (PDD), thus synchronising all activities around this patient, whether in out-patient or in-patient environments. Healthcare is characterised by a range of variability and uncertainty, and, where there is an opportunity to define the process flow tightly, LM can be readily applied. This includes patient flow, but these findings suggested it is more suited to elective surgery or emergency pathways that are predefined. Where the pathway is unknown, poorly defined, and involves transfer of care, flow mechanism is better suited to TBM. This research contributes to new knowledge by providing a deeper theoretical understanding of different manufacturing flow mechanisms and how these mechanisms can be used selectively in various healthcare environments