MANAGEMENT: PRODUCTIONFLOWANALYSIS

Production flow analysis:A tool

for designing a lean hospital
SAULIKARVONEN
MANAGEMENTCONSULTANTAND MANAGINGDIRECTOR,SKA-RESEARCHOY

DR HEIKKIKORVENRANTA
PROJECTLEADEROF FUNCTIONALPLANNINGOF T-HOSPITALAND ASSOCIATEPROFESSORIN
PEDIATRICS,TURKUUNIVERSITY

MIKAELPAATELA
LEADINGARCHITECTAND MANAGINGDIRECTOR,ARKKITEHTITOIMISTOPAATELA-PAATELA& CO

TIMOSEPPL
PROJECTLEADEROF CONSTRUCTIONIN THET-HOSPITALPROJECT,TURKU UNIVERSITYHOSPITAL

xperts agree on the need for a widespread system

redesign in health carel. An ageing population, among
other things, will present hospitals with a new
productivity challenge. System-engineering taols have
demonstrated
significant potential
for health care
developmene and modem research techniques are required
for the planning of hospitals for the future"''.
Organisational barriers play an importam role that restricts
the implememation of new designs in hospitals. Within a
hospiral, individual departments are usually isolated and
behave like functional "SilOS".2Because of this, hospitals are
typically based on functional organisations. Process
organisation4 and process-focused organisationS are both
actually synonyms for functional organisation. With such a setup, units specialise in their own particular processes and
facilities with similar functions are grouped together.4.s.6
Traditionallyhospitals' functionallayouts support this concept.7
Laboratories, medical imaging, operating theatre units, and
imensive care units, as well as wards are examples of functional
layout solutions. The disadvanrages of functional organisation
are long throughput times, poor overall process contro!:6

complex patient flows, and long transfer distances.8 Many UK

hospitals transfer patients from one unit to another via lengthy
and complex routes.9 Scheduling and the achievemem of
fluem patiem flow is difficult in such hospitals9
In product organisation or cellular manufacturing, widely
used in modem industry, production cells or lines complete
products, as they have all the facilities they need ta do SO.+,lO.11
The product of a hospital is a treated patiem - not an
Code
0
E
I
K
M
N
P
Q
R
T
U

Process
Stroke unit
Intensified monitoring
Invasive cardiology
Home
Intensive

ca re u n it

Cardiac care unit

Emergency
Neurology ward
Radiotogy
Monitoring
Ultrasound examination

MANAGEMENT: PRODUCTION FLOW ANALYSIS

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20

patient flow systems ta help in the planning af a new, acute

hospital. PFA is a pragmatic technique that has been used ta
pIan a change from functional organisation ta product
organisation in industry4,1O,1lBurbidge also defines PFA as a
technique for planning the simplification af the material flow
systems for factories: In this paper, we have used care-line
organisation as a synonym for product organisation, The terms
af product organisation are based on an industrial frame af
reference. The terms af care-line organisation better illustrate
this organisation model from a health care viewpoint.

PRN
Number of patients
KPRPQK
1,200
KPK
1,000
KPRPEQK
700
KPRPDRDUDQK
517
KPRPK
500
KPRPTQK
500
KPRPDRDUDQK
333
KPRPDRDUDUDQK
258
KPTK
500
167
KPRPDRDUDUDK
KPRPMEQK
80
67
KPRPDRDUDIDQK
KPRPDRDUDUDIDQK 33
33
KPRPDRDUDNDQK
33
KPRPDRDUDEDQK
20
KPRPMQK
KPRPDRDUDUDNDQK 17
KPRPDRDUDUDEDQK 17
KPRPDRDUDMDQK 17
KPRPDRDUDUDMDQK8
6,000
lIumbor of palionls

Case study: Turku University Hospital IT-HospitaL]

PFAwas used in a study af the patient flows between different
units af a new, acute care hospital; the T-Hospital in Turku,
Finland, The hospital will be completed in 2011. Our target
was ta study and simplify patient flow in the hospital by PFA
in order ta achieve the advantages af care-line organisation.
Currently, the hospital is functionally organised.
The patient flows were analysed tagether with the key
personnel
af the five main care-lines (cardiology,
traumatalogy, neurology, surgery, and other medical (nonsurgicaD treatment). AlI patient flow data is based on the carelines' evaluations af increases in patient volumes between
now and the year 20 II. Following this, emergency, radiology,
laboratary, intensive care, operating theatre units, and
maintenance gave their comments on the route data. PFA's
subtechnique, factory flow analysis, was adapted into the
steps af the project: The patient flow af each main care-line
was analysed by the following steps:

individual operation or examination. In hospitals, product

organisation means that all staff and appliances used in the
treatment af illness are grouped tagether as a multiprofessional group that completes patient's care. Therefore,
product organisation supports patient- and treatment-focused
health care. The well known benefits af product organisation
include quicker throughput times, better quality, smaller
inventories, and smaller inventory-carrying costs4,IO,
in addition
ta better controllability af overall processes:.61OIn the UK, the
National Health Service accentuates the elimination af

A. Analysis:
1. Code processes in the care-line identified with a code letter
(Table 1).
2. Finding process route codes (PRC) for all patients.
3. Printing out the PRC frequency chan (Table 2),
4. Calculating the numbers af patients' transfers between
processes and printing out the from/ta chan (Table 3),
S. Drawing a patient flow network for 2011, based on
functional organisation (Figure 1).
6. Drawing a primary patient flow network for 2011, based

unnecessary patient transfers and a reduced risk af delay while

transferring the patient ta another phase af care as benefits af
the product-based layout in high volume patient care.?
The objective af this paper is ta demonstrate how
production flowanalysis can be applied ta analyse and simplify

TO
D

Stroke unit (D)

intensifiell

monitoring

(E)

Intensive care

_0

(II)

Emergency(P)

M lIellrolo!IY

II

50

100

25

50

'1

1000 1500
780

U
2000

20

80

4725
830
100

700

100

1200 4500 1000

4500

9000

2000
5225

830

100

125

50

4500

3500

500
2000
6000 1000 2000

6000

home(K)
5225

830

100

125

50

10500 3500 6000 1000 2000

5225
830
100
125
50

1500

10500

3500

3500

500

1000
2000

6000

6000
500

:!:interna' transfers

500

50

1500

Ultrasounll examiniltion (U)

home:!: tutal

125

50
1500

:!:internai transfers

ward ('1)

Radio'o!IY (R)
-- Monitoring (1)

:!:tutai

50
25

(M)

monitoring

100

'mrnsive tardio'o!IY (1)

Cardio'ogit

23330
6000

MANAGEMENT:PRODUCTIONFLOWANALYSIS

II

~'

on functional organisation. Primary flow is based on the

Paretoprinciple, in which 20 % of the PRCscovers80 % of
the care line's patients (Figure2a).
B. Synthcsis:
7. Drawing a streamlined primary patiem flow network in
2011, based on a care-line organisation (Figure 2b).
The Figures 1 and 2a represem neurology patiem flows in
functional organisation. The patiem flow system network
(Figure 1) covers all the neurology patients who use 20
differem process routes (Table 2). However, patiem flows are
concemrated in a few process routes which compose a
primary patiem flow. Figure 2a represems neurology's
primary patiem flow in which 80% of the patients use the
seven most importam process routes (PRNs 1-7 in Table 2).
Back-flows between radiology and emergency, radiology and
the stroke unit, plus ultrasound examinations and the stroke
unit reduce efficiency and risk patiem safety.The targets are ta
eliminate the back-flows and place the primary flow's units
next ta each other or join some of the units tagether.
The streamlined patiem flow model in care-line
organisation is presemed in Figure 2b. The streamlined
patiem flow model would reduce neurology's patiem transfers
between departmentsby nearly70%(from23,300 transfers ta
7,300). The streamlined patiem flow requires the elimination
of the back-flows (Figure 2a) by the decemralisation of
ultrasonic examination and other medical imaging. Thus, the
emergency unit has its own radiological functions (Rad1); the
unnecessary boundary between emergency and radiology can
be eliminated. Similarly, the stroke unit has its own
ultrasound functions, and the CT imagingIMRl (Rad2) are

placed immediately next to the stroke unit. Streamlined flow

can be largely implememed. When the streamlined flow
(Figure 2b) is compared with taday's flow (Figure 2a), the
streamlined flow provides the following benefits for acute
neurological patients:
... Quality of care can be improved because patients'
unnecessary and potemially risky transfers are reduced.
... Direct personnel cost savings because much fewer
personnel are needed for patiem transfers between the
stroke unit and radiology (ultrasonic, CT or MRl).
... Development of team work, when most of resources
needed in the patiem care are located close ta each other.
Better team work supports cominuous care process
improvement.
... Indirect cost savings. The following factars comribute ta
indirect cost savings:
i. The delays and errors caused by transfers are eliminated.
ii. Nurses spend their working time in the stroke unit and
not transporting patients, their productivity can be
increased.
iii. Elimination of referrals between units - referral is not a
value-adding activity.
iv. The transfer appliance costs and lift load are reduced.

The four other main care-lineswere analysed in the same

wayas acute neurology.Then all main care-lines'PRCswere
summed up and the emire hospital's from/ta chart for
primary patiem flow was primed out. The primary and
streamlined patiem flows of the main care-lines and the
hospital's primary flows were essemial inforrnation for the
layoutplanning.
Conclusion
PFA is a substamial taol for acute hospitallayout planning,
where high velocity patiem flow is a critical goal. This type of
analysis supports such planning by indicating with good

MANAGEMENT:PRODUCTIONFLOWANALYSIS

certainty which functions should be placed next ta each other.

PFA challenges the prevailing practices of functional
organisation and offers a starting point for streamlining the
patient flow system. PFA illustrates the complex patient flow
pattem in functional organisation.
A notable finding is the dominant position of medical
imaging within all five of the main care-lines' primary flow.
Medical imaging has a central role at both ends of the care
process; at the beginning in the emergency unit and at the
end in the wards (e.g. neurology case, Figures 1-2). Medical
imaging should be ubiquitaus in an acute care hospital. This
can be achieved by well thought-out decentralisation, which
contradicts the prevailing principle of functional organisation
that tends ta centralise imaging facilities under the radiology
function. In care-line organisation, the imaging facilities are
located in close proximity ta care-lines' needs. This can half
patient transfers betWeen units in an acute care-hospital;
transfer distances can be reduced by more than 50%. In the

demonstration unit, Hendrich has showed the value of not

transferring patients from unit ta unit.12Every time a patient
is transfer.red, the patient comes into contact with another 25
or so caregivers.12The benefits of care-line organisation are
additionally supported by tWo findings: the patient transfers
from unit ta unit are a potential cause of quality deviations 12,13
and they generate significant indirect costs.14
Hospitals' labour productivity and patient flow velocity
should be increased. Cur.rent functional organisations tend ta
increasingly reduce the productivity because nobody is
responsible for the entire patient flow management and
patient transfer distances are long. In the future, increasing
numbers of (frequently older) patients will need more health
care personnel ta transfer them via complex process routes.
Functional layout generates unnecessary waiting times
betWeen departments and hospitals' corridors will be more
likely ta get blocked during peak hours.
Functional organisation prevents the use of the theory of
constraint (TOC), a modem production control principle.1516
TOC aims ta maximise a bottleneck's utilisation as the
bottleneck deter.rnines the throughput of the entire system.
On the other hand, maximising non-bottlenecks' utilisation is
useless15.16In functional organisation, each function tries ta
maximise its own utilisation, whether or not the function is
the bottleneck of the patient flow. Therefore, functional
organisation sub-optimises and generates unnecessary costs
continuously. On the contrary, in care-line organisation, a
patient flow manager could focus on bottleneck utilisation
because he/she manages whole patient flow including
inter.rnediate support activities.
One of the biggest challenges ta modemising acute
hospitals is ta implement the organisational change from
functional organisation ta care-line organisation. As a result of
this change, the value-adding units in care production, such
as emergency, operating theatre, medical imaging, intensive
care, and so on, no longer behave like functional silos but
rather support care-line organisation and so achieve high
velocity patient flow, in addition ta high quality care. Modem
layout planning plus PFA will support this target of high
velocity patient flow. [)

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