In the previous sessions, we took a first step from the 30,000 foot perspective of health policy or healthcare economics to the clinical reality of care. But our analysis was so based on treating what happens inside the intervention radiology department as one black box. Today, we want to make another step towards observing the care at the front line. To start, we take the perspective of the patient, and we follow the patient step by step as he or she moves through the process. Being inside the unit we learn that the patient goes to the following steps; they register, and then get an initial consultation with the doctor. Next, the procedure room where the patient are prepared, followed by the actual procedure. After the procedure, the equipment is removed, and the patient is given time for recovery, followed by another consultation. We also learned that the unit has two procedure rooms, a main room and a secondary. Let's visualize a journey of our first patient with a little animation. The patient arrives. She registers at the front desk, where she gets her initial consultation with the doctor. Next the procedure room is prepared and so is the patient. Now, it is time for the actual procedure. After the procedure the equipment is removed, and the patient is given time for recovery, followed by the other consultation. This is a flow of the process for one patient. Let's go back to our notes from the day we observed [inaudible] together. We know that patient arrived at 7:45. We also know that this patient left the unit at 10:05. That's a flow time was two hours and 20 minutes. But what happened during this time? We really have no idea. So, we go inside the unit and ask the folks working there. With modern patient flow systems, we probably could also have done some data collection from the computer, but let's just ask the folks here on the front line. We know that patient, the first patient came in at 7:45, at 7:55 a technician prepared the main procedure room. At 8:05 the procedure started. It was done in 9:35. At 9:40 the patient was freed from any equipment and was moved to recovery. There the final consultation happen before the patient left at 10:05. Because the resulting chart Gantt chart. A Gantt chart is a graphical way to illustrate the durations of activities, as well as potential dependencies among them. The word Gantt chart comes from the 19th century industrialist Henry Gantt. I have no idea if this guy used these charts or not, but that's where the name comes from. Now, contrast this experience of patient one with what happened to patient eight. Patient eight came at 12:35 but as you can see in the Gantt chart there's a big gap. Notice that the patients spent an hour after the consultation. But before being prepared for the procedure. What happened during this time? You guessed right. The patient was waiting as the room was not yet ready from the previous patient. Waiting is a common activity that many of us associate with health care. Now strictly speaking, waiting is not an activity, it doesn't add any value to the process, it's very different from the time the patient spends in the recovery room. But why is there waiting? Why does the patient has to sit around? Waiting is to speak a medical jargon a symptom of a mismatch between the demand created by our patients, and the supply provided by the hospital. To provide care, lots of things are required, in our case a receptionist, a doctor, a technician, a procedure room and a recovery room. We call these the resources of the process. So, patients are flow units, rooms and providers are resources. Just as we can take the perspective of the patient flowing through the process, or from one resource to another, we can take the perspective of a resource. The life of a patient goes like this, registration, consultation, preparation, procedure, removal, recovery, consultation, done. Life as a resource is different. It goes like this, patient comes in, patient goes out, patient comes in, patient goes out and so on. This gives us two perspectives, the patient perspective and the perspective of each resource. Both of them are a little narrow minded which is why I want to introduce a third view, and that view is called a process map or a process flow diagram. A process map combines a view of the patient with a view of the resource. In a process map we use a box to depict a resource, we use a triangle to capture whatever we have inventory build up, that means potentially patients waiting around, and we use arrows to capture the flow of the floor unit. I admit that in health care the differentiation between the patient in inventory and the patient with the resource can at times be rather sattle. Is a patient over in the recovery unit waiting for the doctor or is she actively recovering? To answer this question ask yourself, is the time the patients spent right now part of the care for that patient or this is only a reflection of us not having time to care for the patient at that moment? Some more definitions. We can't think of the flow of patients as a stream or a river. Consequently, we will refer to the beginning of the process as the upstream and the end of the process as the downstream. I want to point out that we can look at the process at varying levels of detail. We broke up the work happening inside the intervention radiology into eight steps. For example, the person in charge of room preparation or a technician might have a five page long instruction manual on how to do room preparation. For us being interested in patient flow, these details really don't matter a lot.
