Theory of Constraints Healthcare Logic Matters

A Guide to Implementing the Theory of Constraints (TOC)
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Introduction

Logic does matter, it matters a great deal. And perhaps the most important logic that impacts upon us is the fundamental conflict or generic “cloud” that underlies healthcare. If we don’t understand this then we simply can’t move forward. A cloud might sound like a funny name but that is what it is called and that is the terminology that we will use here. You will soon get use to it.

I wrote this cloud after asking someone to explain to me what the fundamental or generic cloud in public service healthcare is. I had an open mind and was interested to see what the response was – and I wasn’t going to do it for them. However, the response wasn’t forthcoming and one popped into my head and that is where it stayed until this page.

There is no point in “telling” the cloud to you, and there is nothing better than working through a cloud together, so lets do that, right now.

We are going to follow the procedure in the PowerPoints called Logical Types, Clouds, & Fantasies and the Reformulated Lieutenant’s Cloud. The rules for constructing systemic clouds are in these presentations and you can use the same approach for any systemic problem. There will also be abundant “symptomatic” clouds that will fall out of this systemic cloud that might better detail your own exact local problem. However, don’t lose sight of this generic cloud, it will be there, either “lying” below or “sitting” on top, or maybe “floating” above your own local description.

Let’s Start At The Start

A cloud is a graphical representation of an underlying conflict or compromise. It consists of 5 elements – boxes actually.

Let’s have a look at these.

The first element is an objective, the outcome that we seek. It is fed by two concomitant needs. The needs are in-turn fed by two “wants” and it is here that life gets interesting. The wants are mutually exclusive. We can have one or the other but not both; well certainly not both at the same time. The wants are in conflict with one another. We indicate this with the lightening-bolt-like set of arrows.

It might be more appropriate to address the “wants” as follows;

If we label one as a “don’t want” and another as “do want” then the conflict is more apparent. The negative or “don’t want,” by convention, is located in the upper position and the positive or “do want,” by convention, is located in the lower position.

Another way of wording these elements is as follows;

The needs can be viewed as requirements in order to meet the objective. The wants, in-turn, can be viewed as pre-requisites in order to meet the requirements. Of course the pre-requisites are still in conflict regardless of how we address them.

Now there is a small amount of short-hand which sometimes helps us in using and communicating clouds and we should incorporate this as well. We simply label the elements as A, B, C, D, and D’ (read as “D prime”).

Let’s have a look at this and let’s also revert to using “needs” and “wants” as the descriptions.

Let’s now fill in the specifics for public service healthcare – in particular non-acute or “elective” services – although the basic cloud covers other aspects as well (emergency department and nursing for example).

Cloud For Public Service Healthcare

We need to work around this cloud filling in the details. We are going to do this in a very specific sequence; clockwise from D then D’ then C then A and finally B. There are good reasons for doing this.

So we need to first ask ourselves what is it about healthcare at the moment that overall we don’t want? What is it that encapsulates all the stuff that we have to put up with in the current reality, indeed that we are often forced to put up with, that we do not like and that we do not want?

If we invoke the wisdom of an 8 year-old, then we can also test our current reality against Quincy’s Rule (1); what is it in D that is the answer to all of our sad questions?

For me, restricted access is the overarching description that best fills this entity. Sure, you may find other ways to express this same concept – lack of access, limited access, and so forth.

Let’s put this in and see.

How many of the current things that we have and that we do not want in public healthcare could be covered by this generalized entity? Or that we can trace back to this entity? Probably almost all of them.

The next entity, D’ is easier. It has to be mutually exclusive, that normally means that it has to be the opposite. It also has to be something positive that we do want in the near future. It also has to be the answer to all the glad questions according to Quincy’s Rule.

Let’s keep it simple and put “full access” as the description that best fills the D’ entity.

Let’s add this.

Let’s run a check. Can we have both restricted access and full access at the same time? Are they in conflict with one another? They would certainly seem to be so. Moreover, if we could have full access would many, or most, or in fact all, of the current problems go away? That would, indeed, seem likely.

So now we must ask what need in C is met by the want in D’ of full access. I think that if we had full access then we could ensure appropriate treatment. And that is the description that I am going to put into C.

Let’s have a look.

Let’s read C and D’ back and see if they make sense. We will use the formula “In order to have C it is necessary that we have D’.” Let’s read this through and see if it works.

In order to ensure appropriate treatment it is necessary that we have full access.

That seems to make sense to me.

Or we could test it using “we must have” rather than “it is necessary that we have.” Let’s try that as well.

In order to ensure appropriate treatment we must have full access.

That also seems to work.

In fact doing this normally flushes a few unstated assumptions out as well. The assumptions are viewed as “sitting” under the C-D’ arrow. They are additional sufficiency in what is otherwise a bare-bones necessity-based logic. Let’s work through the verbalization first and then draw it.

We will just tack on a “because” to the end of our last sentence; “in order to ensure appropriate treatment we must have full access because ... ?”

What shall we put in there? Well, I will put because the treatment is timely. I have no doubt that the clinical professionals will make sure the treatment is appropriate, but the sooner that it is done, the less invasive or disruptive or expensive it is likely to be. Let’s draw this.

Now just a note, full access doesn’t mean trivial access, it means access within agreed clinical guidelines. The public health service is not everything to everybody. There are some procedures that might be regarded as unnecessary or discretionary or cosmetic and are therefore better placed in the private sector. Also some referrals from general practice to specialists, as an example, may go no further than just a referral – they fail to meet the protocols of the specialist for further treatment. But access, and full access at that, to the necessary expertise for such a decision is often lacking or missing at the moment.

In fact we have just uncovered a jeopardy arrow. Let’s have a look.

Ensuring appropriate treatment is a vision of the future, it is not here yet, and in fact its very existence is jeopardized by the current restricted access that we are forced to put up with. C is jeopardized by D. That is; ensuring appropriate treatment is jeopardized by restricted access.

It is not a pretty sight, but let’s keep moving on. Let’s look at the objective in A.

What is the objective that we are seeking to meet? I think that it is quite simple, I think that it should be something as simple as “good healthcare.”

Let’s have a look.

Does that seem like a worthy objective? It is certainly positive.

It seems to make sense, so let’s run our tests and check this out.

In order to have good healthcare it is necessary that we ensure appropriate treatment.

That seems fine, lets check the other wording.

In order to have good healthcare we must ensure appropriate treatment.

That also seems fine.

Moreover, these verbalizations are starting to chase out assumptions “under” the A-B arrow. Let’s have a look.

It is necessary to ensure appropriate treatment because often intervention is the only recourse. Wouldn’t it be great if primary, proactive and preventative healthcare methods worked more fully – they have tremendous potential, and wouldn’t it be great if people would more actively take them up. However, many conditions are still beyond our current control and secondary reactive intervention is the only recourse available to us in order to ensure good healthcare. This is the major assumption here.

Now, this just leaves us with just one more entity, the need in B. The rationale for leaving this until last is that, arguably, it is the most important. It is something that exists within our current reality that is positive in its own right – we wouldn’t knowingly set out to do something negative – and yet it forces us to do the things that we don’t want to do in D. Moreover, the content in B also is absolutely necessary if we are to meet the objective that we have already agreed upon for A.

Therefore, given that A, C, and D’ are so important, and yet we still tolerate D – even though it conflicts with D’ and jeopardizes C – there must be a very powerful and positive reason for the existence of D that resides in B.

What are we going to put here in B? We need to ask; why do we comply with D? Why do we tolerate D? Why are we forced to accept D? What is the positive need in B that is powerful enough to explain this?

We must ask; what is the need that is protected by the restricted access?

Well, I am going to put “protect available funds.”

Let’s have a look.

Protecting available funds is clearly positive, so let’s see if it passes all of our checks.

Let’s look at B-D first.

In order to protect available funds it is necessary to restrict access.

In order to protect available funds we must restrict access.

Or in this particular case (B-D) we might add,

In order to protect available funds we are forced to restrict access.

We don’t want to restrict access but we are forced to so that we can protect our limited funds. Excellent, this seems to make good sense.

What then are the assumptions that support this logic? Let’s have a look.

In order to protect available funds we are forced to restrict access because capacity is determined by funding. That seems like a reasonable assumption to me.

We are almost there, let’s now check A-B.

In order to have good healthcare it is necessary to protect available funds.

In order to have better healthcare we must protect available funds.

That seems fine and, again, this flushes out the last and nonetheless important assumption that lies buried under the A-B arrow. Let’s have look at this.

We have to protect available funds because funding is limited. Healthcare is not the only benefactor of public expenditure, there are many other competing areas as well.

Now we can finally address a disquiet that we may have experienced earlier when we said that if we had full access many, or most, or indeed all of our current problems would go away. You may have wanted to say “yes but,” and that “yes but” was addressing the second of our two jeopardies within the cloud.

Let’s have a look.

Protecting funds is jeopardized by full access. This is why the statement that full access would remove the current problems caused the feeling of disquiet, we probably all went; “yes but we don’t have the money.” We all want to move to a better future but we are locked in place by our present.

So here we have a description of the generic cloud for public service healthcare.

We are locked into a conflict between restricted access in order to protect our funds and full access in order to ensure appropriate treatment. Both protecting our funds and ensuring appropriate treatment are necessary in order to have better healthcare.

Does that feel something like your reality? I trust that it does.

Please note, however, this is not a physician’s cloud. Nor for that matter is it the patients’ cloud, or the tax-payers’ cloud, or the managers’ cloud, or the Ministers’ cloud. Well actually it is all of these, but each of these might have a more specific and local “take” on the matter. The generic cloud must be capable of addressing, at a more symptomatic level, all of the constituents; the funders, the patients and the staff.

Now, nice as that may be, it has yielded about half of the information that is buried within it. You see we are locked into this conflict, and so strongly locked into this conflict at that, that we can’t see a way out. We can’t see a way out because of what we do know of the past and what we don’t know of the future. Our old “know-how” blocks us from accessing a new “know-why.” We are locked in by our own psychology. We need to break out.

Let’s go and have a look for the additional information that locks us in, and then we will search for a key to help us break out.

Hunting For Negative Fantasies

We are not so much stopped by something tangible or physical but rather we are stopped by ourselves. We stop ourselves with negative fantasies (2). Negative fantasies are an incredibly pervasive part of modern organizations and yet we hardly give recognition to their existence let alone their impact. If we don’t acknowledge them, let alone understand them, then how on earth can we manage them and overcome them? Let’s start then by acknowledging them.

First step, how do we find these things?

Well almost the same way that we found the assumptions. We found the assumptions by adding on a “because” to the end of our logical statements. The assumptions are presumed to be reasonable statements of the here and now. To access the future, however, we need to use “otherwise ...” This is the only difference.

Let’s try it out, firstly on the restricted access side.

In order to protect available funds we must have restricted access otherwise ...?

We have to ask what is the “otherwise,” and my interpretation is as follows;

... volume will rise & costs will balloon

Let’s draw this in.

”Costs will balloon” is negative, and it is also placed into the future. We fear that volume will rise and costs will balloon and we will not be able to protect available funds anymore. In fact to put it more succinctly, or maybe more frankly, we simply fear that we will lose control.

Lets add this as well.

A negative fantasy has a personal aspect to it, we personally fear that volume will rise, costs will balloon, and we will lose control. Moreover, the fear that that costs will balloon if volume rises is founded upon our past experience, our past reality, we know only too well how easy it is for this to happen.

If we look a little harder another distinction that makes negative fantasies different from assumptions becomes clear. Assumptions are about the side of the cloud where the assumption appears. Negative fantasies are about the other side of the cloud. Our negative fantasy is about the consequences of full access coming about. The negative fantasy is the rationale that we can use to continue to substantiate or rather entrench restricted access.

OK, then, what about the other side of the cloud? Is there a negative fantasy on that side too?

Let’s have a look.

Once again we need to use our “otherwise” to flush the verbalization out.

In order to ensure appropriate treatment we must have full access otherwise ...?

We have to ask what is the “otherwise,” and my interpretation of the “because is as follows;

... acuity will rise & costs will balloon

Let’s draw this in.

Oh wow! Do you see that? Once again “costs will balloon” forms the negative fantasy, although this time it is driven by rising acuity. Again this negative fantasy is about the other side. We know from past experience that restricted access only results in some people becoming even more ill until they have to be seen or they present as an acute patient. The negative fantasy is that this will become worse and worse.

Is there a similar entity about control? Well I think that there is, its similar but different.

Let’s have a look.

On this side we don’t fear losing control, we fear that we won’t gain control of the situation. People’s health will become worse and worse, the acuity will increase and costs will balloon.

Let’s put the two sides together.