Article 71.  Three levels of Throughput- Current, Capable and Required

When we examine Throughput we find that there are three levels of Throughput:
1. Current Throughput (number of patients processed in specific areas) determined by hospital records.
2. Capable Throughput determined by employee Lean Team studies and a Throughput Schedule using current staffing.
3.  Required level of throughput to meet Veteran schedules.  This is arrived at by expanding the Capable Throughput Schedule adding staffing until the Required level is reached to satisfy appointment schedules.

How this process can be implemented
The problem: determine waiting Veterans Health Care Needs and the added impact on VA hospital capabilities followed by the increased staffing to meet requirements.

Approach for Quickly meeting Veterans’ Health Care Needs
1. Make sure all Vets Who want an appointment are added to the electronic appointment Schedule.

2. Make a detailed assessment of each patient’s medical needs to determine where and by how much the VA Medical Facility will be impacted.  I recommend a mass screening of the 1700 new patients at the Phoenix VA with interviews and blood tests.  By reviewing 100 patients a day the task of finding what the patients health care needs are can be completed in a month.  The impact on the Medical Facility will be an estimate because more precise numbers are beyond the expertise of the VA.

3. For the Identification of exactly where the VA hospital is going to be impacted with the required increased staffing I recommend that immediate attention be given to the following:

A. Identify all systems processes affected by increased patient loads from the mass screening and establish an employee functional Lean Team for each set of processes.  Empower the Lean Teams in these areas to come up with the most effective and efficient approach for doing the process. 

B. Establish a second level Doctors Lean Team to determine the Capable Throughput with current staffing using the data developed by the Functional Lean Team to create a balanced work flow Throughput Schedule.

C.  Find the Required level of throughput to meet Veteran schedules.  This is arrived at by expanding the Capable Throughput Schedule adding staffing in balanced sets until the Required level meets Veterans Appointment Schedules.

This approach will also identify the need for equipment and machines to be purchased by the VA.
  
Note that the objective of the balanced work flow is to eliminate excessive waste time due to members of a Team waiting on other members.  This a staffing balance with each employee's duties rated at 75% this means that the time to do a process at 100% is increased to 125%.  The reason for this is that it avoids delays caused by inexperience employees or other reasons that may impact the entire Team.  The absence of a team member can significantly impact the entire Team causing all members to wait.  To avoid this problem I would have a standby nurse who will do routine support activities such as ordering supplies that can be available to fill the void.  It is possible although not required that an experienced Team can work consistently at 100% increasing the number of patients served.    

Example of Psychiatric Veteran Needs
Because the level of need in this area is so great to prevent suicides and domestic violence.  I recommend the following approach:

Follow the above approach for immediate action then Convene a Medical Advisory Board of the best minds in the Psychiatric field for recommendations and suggestions.  This is followed by a second Required level of Throughput Schedule to implement the new recommendations and suggestions as Best Practices which can be applied in all VA Health Care Facilities.  Note that Psychiatric and Physical Therapy patients are dependent on the condition of the patient and not on the time spent with the doctor.

Each VA Health Care Facility will have a different Vets appointment Schedule.  Only the building of the Required level of Throughput to meet the new Facility's Veteran schedules is needed.  This is arrived at by duplicating the original Capable Throughput Schedule and expanding it to meet the new Facilities staffing requirements level thus satisfying the new appointment schedules while providing the highest effectiveness (Best Practices) and the greatest efficiency.

If the original Capable Throughput Schedule is expanded each time a Doctor is added we can determine the corresponding: number of nurses needed, equipment needed, and number of patients for a balanced work load.  Also with each step we can determine the added floor space required. Now we have the data needed for all VA Medical facilities by matching the increased patient load for each medical area to one of the balanced steps based on the number of doctors required yielding the patient load that meets the appointment schedule requirements.  This is not an estimate but an actual balanced work flow of doctors, nurses, and equipment for given patient load.

Before new computer systems can be built to estimate Staffing requirements at VA facilities there must be a solid footing of actual data to backup the new systems. The quicker this data is generated and proven the sooner computer systems can be developed.  The problem is that the data can be quickly generated within two months but the computer systems will take as much as a year to develop time that the VA does not have.