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A Guide to Implementing the Theory of
Constraints (TOC) |
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Additional
Comments There are a
number of things that I want to say that should have been said on the previous
page that heads this section. But that
page has a job to do and that job is to remind us that some of the things
that we embrace in healthcare today may not yield us much benefit in return
for the effort expended. This is not
because the tools are deficient, but because the focus is more analytical
than systemic, and more attuned to quality for it’s own sake than as a driver
of productivity. Without improved
quality we can not have improved productivity, but it is more than possible
to have increased quality and yet have no increase in productivity. That may seem
harsh, but then healthcare would have to be exceptionally different to have a
different outcome from other organizations.
I don’t believe for one moment that healthcare is exceptionally
different. There is only one
fundamental issue as I see it – a lack of systemic understanding – and almost
all modern organizations experience it.
And if we aren’t prepared to learn from other organizations’ failures,
then we are most certainly destined to repeat them. That would be like banging our heads
against a brick wall in the hope that the pain will go away – it won’t, at
least not until we knock ourselves senseless.
How often have you just wanted to give up on improving
healthcare? That is the equivalent of
knocking yourself senseless, you just give up, so you know what I mean – do
you not? In fact, for
healthcare to be exceptionally different from other organizations, then the
people in healthcare would have to be exceptionally different as well, and
that is not the case, that is why I am certain all organizations share a
commonality in their problems.
However, we don’t have to keep repeating the problems – do we? Normally, I’d
hardly budge an inch that any particular industry could claim “difference”
even though every industry is apparently different. We’ve addressed this many times
before. In terms of detail complexity,
every industry and indeed even some firms within the same industry are
different. And the staff in those
organizations are firmly on the ball with regard to the detail of their
differences. The detail differences
are their competitive advantages believe it or not. We are not shy to analyze such detail
complexity either, sometimes were overwhelm ourselves with such
analysis. But there is another form of
“complexity” – dynamic complexity. I
have argued, and will continue to argue, that dynamic complexity isn’t complex, it is our lack of understanding that complicates the interpretation. So why then does healthcare think that it is
different? Healthcare is different because we have the blessed patient in the system!
Indeed some of them won’t stay away! Healthcare is different because it is a service. Sure, there are many types of services, but
here is one that is often critically time dependent. I can think of only a few other critically
time dependent services – mostly, but not exclusively, in the
armed-services. Think about it. Amongst my
treasures is a letter from an otolaryngologist informing me that healthcare is
not like the manufacture of a can of baked beans. Also in my possession are several e-mails
ensuring that I understand the difference between patients and sardines. This is all very informative both for what
it says, and also for what it doesn’t say. What these comments say is that the analogies are simplistic, and maybe
that was for my benefit – after all, people from industry are not too bright
– right? However, it might also be a
measure of a lack of knowledge or a lack of exposure from within medicine to
the outside world – the world of industry and commerce from which there is so
much to learn; both in terms of what to avoid and what to embrace. What these comments don’t say, is the frustration of those involved in
expressing why their industry, healthcare, is not like, let’s say, a can of
beans. We get an analogy of a can of
beans or a tin of sardines which implies simplicity, uniformity, and
repeatability. So what it doesn’t say,
except by difference, is that healthcare is far from simple, far from
uniform, and far from repeatable. That
is, it is a service, one that is often highly individualized, and full of
variability. These comments suggest a
retrospective longing for apprenticeship and make-to-fit craftsman, rather
than the apparently soulless modern world of industrialized make-to-spec. You know the
detail complexity of this already, that is why healthcare professions train
for so long and continue to retrain throughout their lives – and that is why
we have to have specialists in addition to generalists. What then of the so-called dynamic
complexity? Now things start to get
interesting. Let’s have a look. You see, we
hardly address dynamic complexity at all.
We expect the specialists and generalist of healthcare detail
complexity to somehow informally “learn” about so-called dynamic complexity
through the school of hard knocks. The
reality however is that we don’t learn what we ought to. We are constrained in scope to performing
according to some local performance measures even when common sense suggests
to us that this is counter-productive. So what then
of formal learning? Mintzberg has this
to say of business in general; “Production (or, as it is now called,
operations management) has long been a marginal area in many business
schools, with relatively little attention from the students and often not
much more from the faculty (1).” How
can we expect good things in healthcare if the material isn’t even taught well
in general business? Maybe the only
people who are regularly exposed to such material are engineering students. Well all is not completely lost. There is an introductory book on systemic
approaches to healthcare (2) and more recently a text has been published on
focused operations management for health service organizations (3). In the introduction of this latter book Donald Berwick makes a prescient comment that “bridging between
intellectual pursuits previously unfamiliar with each other requires translation,
patience, and an attitude of respect among strangers.” And maybe this is the crux of the matter
here. An attitude of respect among
strangers would go a long way to bridging the gap that currently exists
between the informal and formal knowledge of operations management extant
within healthcare organizations and the systemic knowledge that exists
“outside” but is mostly missing from within. There are
strangers around who see into healthcare and don’t see “differences” but
rather see only “similarities.”
Individualized service that is highly variable is not new territory
for some. If you will try to listen,
you may begin to hear this. If you
will look, you may begin to see this.
If you will try and do, you will begin to learn this. If you will
extend tolerance to strangers for a moment, and the use of funny words, I
will explain why healthcare is a basic solution. The fundamental logistical solutions in
Theory of Constraints are built around; § Production – called Drum, Buffer, Rope or DBR for short. § Supply Chain – called Replenishment and applies to both inwards flows
(marshalling) and outwards flows (distribution). § Projects – called Critical Chain Project Management or CCPM for short. What are the
distinctions? Production involves the
repetitive “making” or “conversion” of something. Supply chain doesn’t make things, but it
does transfer made things. If you
like, it is a service with a tangible product. Projects are similar to production except
the touch time involved in the “making” is hugely greater than in production,
and usually there is an element of increased variability – usually
uncertainty – associated with the project. All three are
fundamental to healthcare. On another
page, replenishment and healthcare, I have described the whole of public service hospitalization as a
supply chain, in fact a marshalling chain.
I want to leave that as it is.
In the next 3 pages I want to address the specifics of logistical
solutions to; § Emergency department § Non-acute or so-called elective surgery § Nursing & discharge Each of these
are distinct parts of the overall supply chain. I want to suggest that you read through
whatever parts are of relevance to you.
Then, if I haven’t done a good enough job of the explanation, go to
the sections on this website that address the fundamental logistical solution
which is of direct relevance. The
explanations of the fundamental logistical solutions are non-trivial. You will be very hard pressed to find
comparable explanations in print, and to my knowledge this is the only place
you will find all three. If you need a
frame of reference please go back to the preface. You are going
to be exposed to a new know-why (theory) which will cause you discomfort as
you jettison old know-what (facts or information), and replace them with a
smaller set of cutting-edge new know-what.
But this will only happen if you are willing and able to relax or
suspend your current know-how. That
really is the challenge that we are about.
Doing something and experiencing it is the only way to replace your
old know-how with the necessary new know-how.
In fact, it is not new know-how, its just novel to you at the moment. Let me labor
this from a different direction. We
fill our world with explicit data from which we winnow information, Gregory
Bateson calls data “differences,” and information, “differences that make a
difference” (4). This is a subtle but
important distinction. Out of this sea
of data our new “know-why” will cause us to examine and find new “know-what,”
differences that make a difference, but once again, we must not let our old
“know-how” block us from doing this.
In fact, one more time; Don’t let old (reductionist)
know-how block us from learning new (systemic) know-how There is an
inherent simplicity in healthcare; it comes from an understanding of the
dynamics of the processes, and it comes from an understanding of some of our
own mis-conceptions. And this is no
different from most other modern organizational endeavors. In the next 3 pages we will address the 3
basic solutions that apply to public service hospitalization. And as a stranger I will make a plea for
tolerance for a slightly mechanistic approach. There is a reason for this. You already
know the messiness, variability, and uncertainty of everyday healthcare, it
hardly needs to be revisited. But if
you don’t understand clearly the underlying mechanics you won’t be in a
position to understand the interaction between the mechanics and the
variability and uncertainty. If the
solutions are reduced so that they are simple, don’t mistake this for
simplistic. In any case there will be
no shortage of people wishing to complicate them for you. That seems to be human nature. I believe that
it is impossible for anyone with an interest in healthcare and a knowledge of
drum-buffer-rope to not see the direct implication for non-acute surgical
intervention – assuming of course that you consider that there is
insufficient capacity. I owe a debt of
gratitude to Katherine O’Regan, Member for Parliament and former Associate
Minister of Health for listening and trying to elevate this approach to
non-acute surgical intervention at a time when the only published record was
the Radcliff neurosurgical success (5). I wrote up an
article at that time for national consumption, however, it was rejected by an
anonymous referee. I realized then and
there that evidence-based medicine isn’t.
I shouldn’t beat-up healthcare, it is part of the paradox of being
human that this approach comes up against.
But still if new ideas are not allowed to be aired, how can anyone
learn. Part of the beauty of the
internet is that the referees can now go to h...elp somebody else. There are so
many positive things that can be done in healthcare we should just get on
with it. Let’s do exactly that. (1) Mintzberg, H., (2004) Managers not MBA’s: a hard
look at the soft practice of managing and management development. Berrett-Koehler, pg 89. (2) Wright, J., and King, R., (2006) We all fall down: Goldratt’s Theory of
Constraints for healthcare systems.
North River Press Publishing, 353 pp. (3) Ronen, B., Pliskin, J. S., with Pass, S., (2006) Focused operations
management for health service organizations.
Jossey-Bass, 354 pp. (4) Bateson, G., (1979) Mind and nature: a necessary unity. Hampton Press edition (2002), 223 pp. (5) Phipps, B., (1999) Hitting the
bottleneck. Health Management
Magazine, February, pp 16-17. This Webpage Copyright © 2008-2009 by Dr K. J.
Youngman |