Theoretical models

3.4.1 Framework for healthcare planning and control

In order to decide the best possible way to organise and design the elective admission ward, the framework for healthcare planning and control of Hans and Houdenhoven (2011) is used. This framework integrates all the managerial areas that are involved in the delivery of healthcare and all hierarchical levels of control. The framework can be used as a tool to structure and break down the different functions of healthcare planning and control. The framework consists of 4 managerial areas and 4 hierarchical levels21. The model can be found in Figure 10.

Figure 10. Framework for healthcare planning and control

There are different managerial areas, but the area the elective admission ward is focussing on is the resource capacity planning. The resource capacity planning includes the dimensioning, planning, scheduling, monitoring and control of resources, which include equipment and facilities. The elective admission ward will be a new facility and therefore it belongs to this category. In order to gain a complete overview of the elective admission ward, it is necessary to take into account all the hierarchical levels.

Strategic level

The strategic level is concerned with long-term decisions, which have a high impact on the resource capacity planning. The problems that are addressed at the strategic level consist of mainly resource allocation problems. This level defines the dimensioning of ward resoures, other aspects dealth with by this level are the case mix planning, layout of the ward and the capacity dimensioning. The layout planning and capacity planning are based on aggregated information, historical data and forecasts for the upcoming years. The planning horizon at this level is one or more years. Every decision that is made on this level influences the decisions that are made at the next levels10,21.

Tactical level

The tactical level addresses the organisation of the execution of the healthcare delivery process. The decisions that are made on this level are depending on what is decided at the strategic level. The layout and capacity planning are used as input for the tactical resource capacity planning. The case mix that is decided at the strategic level will serve

as input for the admission and operation planning and the number of nursing staff that will work on the ward. The tactical planning is more flexible than the operational planning; there is the possibility to increase the capacity temporarily based on the (seasonal) demand and waiting lists. The tactical planning also uses historical data and actual or forecasted demand to make an accurate planning. The planning period for this level lies between the one to three months but it can increase to one year. Because there is still some uncertainty in the demand the tactical planning is less detailed than the operational planning10,21.

Offline operational level

The offline operational level involves the short-term decision making for the execution of the care delivery process. There is little flexibility on this level since most of the decisions have already been decided at strategic or tactical level. The offline operational level is involved in the in advance planning of patients and personnel. It consists of the scheduling and coordination of activities with regard to the current (elective) demand. To calculate and plan the patients both the resource capacity, which includes the regular opening hours, maximum overtime and surgeons available, and time-window (admission and discharge date) are taken into account10,21.

Online operational level

The online operational level also involves short-term decision-making, but it differs from the offline operational level because it deals with unforeseen or unanticipated events. Where the number of patients and nursing staff have already been predicted at the offline level, the online level deals with control mechanisms for unanticipated events. These events can include triage, emergency patients and rush ordering of instruments. Due to these unanticipated events, the existing schedule of the elective patients should be modified to deliver care to the urgent and emergency patients10,21.

Elective admission ward

When looking at the above-mentioned levels for the resource capacity planning it can be seen that there are some levels that are more important for the elective admission ward than others. The strategic level includes the expected case mix, layout and the capacity. This is one of the most fundamental levels since all decisions regarding the patients and the facilities will be discussed at this level. The tactical and operational offline level is very solid for the elective admission ward since only elective patients that are already planned for surgery are seen in this ward. Therefore the appointments and personnel can easily be scheduled in advance. The elective admission ward has almost no planning on the online operational level since the emergency 1 and 2 patients have a different flow than the elective patients and therefore only the emergency 3 patients will be seen at the elective admission ward. However, unforeseen events might occur, nursing staff unable to be present, a specific patient needs more care than expected beforehand or there are other problems at the inpatient wards that require a response on the online operational level of the elective admission ward.

3.4.2 Lean principles for a hospital

There are different principles that can be used to optimise the care process for the patients, whereby one of these principles used a lot is Lean. Van Vliet (2011) developed an analytical framework based on six main aspects on which the hospital processes can be measured from the lean perspective. The six aspects are: operational focus,

autonomous work cell, physical layout, multi-skilled team, pull planning and elimination of waste. Each of these aspects will be discussed in more detail below22_.

Operational focus

The operational focus aspect of lean thinking is the focus on the quality of the care, the reduction in lead times or flows and the reduction of costs. The goal is to reduce the time the patient spends in line by removing all steps that do not add value.

Autonomous work cells

The concept of the autonomous work cells shows that all activities that are necessary per patient should be conducted within three workstations. The work cells reduce the risk of processes interfering with each other. Therefore all involved workstations should be organised in one work cell to the possible extent.

Physical layout of resources

This aspect of lean ensures that the risk of delays in the care process is minimised. These delays can arise when the physical boundaries of autonomous workstations need to be crossed or the consecutive activities that are performed in the care process.

Multi-skilled team

One aspect that can influence the flow of the care process is the flexibility of team members to conduct tasks interchangeable. This means that all members of the team are competent to execute the proceedings in the care process.

Pull planning

Pull planning means that the resources should be coupled to the activities directly and on demand. If the activities are coordinated separately this can lead to a decrease of flow and eventually to waiting times for patients and staff. Elimination of waste

The last aspect of lean thinking is the elimination of waste. This means that activities that do not add value will be eliminated as much as possible. These activities include overprocessing, motion and transportation of patients, waiting for staff and patients, and inventory depository22.

Elective admission ward

When looking at the available literature about the elective admission ward it shows that all Lean principles should be examined for the ward. The main reason for the development is to reduce the lead-times for patients undergoing surgery by positioning the elective admission ward next to the operating theatre. There is a skilled team, which can perform all necessary procedures, and the patient will be helped as soon as possible to make sure that they are well prepared for their surgery. The ways in which the waste can be eliminated to make sure that the patient flow is optimal will be investigated by comparing the results of the interviews of the hospitals.