Setting the Drumbeat - An Example

True demand has already been identified and measured. This is the ‘drumbeat’ that the patients set for the process.

If the work is going to flow through the process with no queues, delays and bottlenecks, process capability needs to be matched with this drumbeat. Every part of the process needs to be working to this same rhythm.

Let’s look again at the anticoagulant clinic that was the subject of Process mapping

The clinic is held between 9.00 a.m. and 1.00 p.m. Let’s say that, on average, 48 patients need to be seen in the four-hour session. As there are 240 minutes in a session this means that one patient needs to be processed every 5 minutes (240 divided by 48) in order to satisfy the demand.

This is the drumbeat for the process – “one patient every 5 minutes”.

If the process was perfectly synchronised to this beat, each box on the flowchart would operate once every 5 minutes. Following some improvement work, the process in the anticoagulant clinic could look like this:

Figure here

The blue figure in each box is the length of time it takes to carry out that activity. Therefore, the ‘cycle time’ for the whole process shown here is 14 minutes (0+4+3+5+2).

When the whole process is synchronised with the drumbeat, demand is met perfectly and each patient is dealt with in the fastest and most efficient way.

The first patient would be called at 9.00 a.m. and would leave the clinic at 9.14 a.m. The 48th (i.e. last) patient of the day would be called at 12.55 p.m. and would leave the clinic at 1.09 p.m. (you can work this out for yourself if you like).

A patient could plan to arrive at the clinic at, say, exactly 10.05 a.m. in the certainty of being dealt with straight away and would know that they would be walking out of the clinic at precisely 10.19 a.m. The person who brought them to the hospital could simply drive round the block and pick them up again – and incidentally eliminate the “tries to park car” problem box on the original process map!

To achieve this you would need to ensure that the INR test machine was ‘right-sized’ to operate at this speed – it doesn’t need to operate any faster (see more about right-sizing in the section on flow), and you would need to ensure that the resources required at each process step are geared up to the drumbeat.

If you can take a patient’s blood sample in 4 minutes why should you wait for five minutes between each patient? Could you speed up the process by calling patients and taking their blood every 4 minutes? No – if you did this you would simply create a bottleneck and queue at the fourth box on the flowchart above. You would have patients arriving every 4 minutes at a process step that takes 5 minutes to complete. It is better to maintain a smooth, steady, controlled rhythm.

The ‘result analysed’ activity above is what you might call your ‘pacemaker’ activity, and it is a critical activity in the process. If it starts to take longer than 5 minutes the whole process starts to over-run and you fail to meet demand.

What if you found that the ‘result analysed’ activity could not be carried out in less than 6 minutes? If this was the case you could try to improve this activity and reduce its time to 5 minutes. Failing this you would have to run clinic sessions from 9.00 a.m. to 2.00 p.m. or double up on the resources employed in that activity, etc.

What if the ‘result analysed’ activity was improved and it was found that it could be carried out in 3 minutes? ‘Blood sample taken’ would then become the pacemaker activity and you could either reduce the session period or plan to take on more patients per session, by increasing the drumbeat to “one patient every 4 minutes”.

You are probably already thinking by now, “This is all very well, but how likely is it that the clinic will receive exactly 48 patients every day?”. The truth is, “Not very likely!”. When the original process map was drawn it was noted that the actual number of patients arriving each day varies between 45 and 65. On top of that, all of you ‘blood-takers’ out there will already be screaming by now, “Hang on, have you tried getting one spot of blood out of some of our patients’ arms in four minutes?” Sometimes things just don’t go according to plan. Everything varies, and variation is a much bigger problem than most organisations realise. It will ruin your best-laid schemes. But help is at hand. A tool called a Process Behaviour Chart was invented solely to help you deal with variation. If you are to realise the full benefits of making a process flow and synchronising the whole process in line with demand, you will need to reduce variation in demand as much as you can. This is often easier to do than you might think. Variation is a major problem everywhere in an organisation, not just in the area of demand. Knowing how to use a Process Behaviour Chart, understanding the causes and nature of variation, and knowing how to deal with variation effectively are amongst the most powerful things an organisation can learn.

When you have

you have carried out some very impressive process improvement indeed!