A Guide to Implementing the Theory of Constraints (TOC)





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Emergency Department

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Logic Matters




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?

What Is Different About Healthcare

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.

Cans Of Baked Beans & Tins Of Sardines

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.

Healthcare Is A Basic Solution

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.

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