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A Guide to Implementing the Theory of Constraints
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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 |